V  I  620 

3666p 

1870 


alifornia 
rional 


THE 


LPHYSICAL  EXPLORATION 


K  E  C  T  U  M ": 


WITH  AN  APPENDIX  ON  THE 

LIGATION  OF  MfflOBRHOIDAL  TUMORS. 


BY 

WILLIAM  BODEiraAMEK,  A.M.,  M.D. 


"  The  accuracy  of  our  diagnosis  is  in  direct  relation  to  the  thoroughness  of  physical 
exploration."— PROP.  G.  T.  ELLIOT,  JK. 


ILLUSTRATED  BY  NUMEROUS  DRAWINGS. 


NEW    YOKE: 
WIIyLIAM    WOOD    &    CO.,    61    WALKER    STREET. 

IST-O. 


\/J  J_  fl  to  P  O 


Entered  according  to  Act  of  Congress,  in  the  year  1870,  by 

WILLIAM     BODENHAMER, 
in  the  Office  of  the  Librarian  of  Congress,  at  Washington,  D.  C. 


J.  O.  SEYMOUR,  KENNARD  &  HAT, 

Printers  and  Stationers, 
89  Liberty  Street,  New  York. 


PREFACE. 


THERE  are  but  few  minor  operations  of  surgery  that  require  more  knowl- 
edge, experience  and  tact,  in  order  to  be  enabled  to  perform  them  efficiently 
and  satisfactorily,  than  the  physical  exploration  of  the  rectum,  including  the 
sigmoid  flexure  of  the  colon.  The  natural  obstructions  in  the  way  of  such 
an  examination,  in  these  portions  of  the  intestinal  canal,  are  many,  and 
others,  still  more  numerous,  may  be  found  from  disease  and  other  circum- 
stances. These  various  difficulties  can  only  be  successfully  met  and  over- 
come by  a  complete  knowledge  of  the  anatomy  of  the  parts,  both  natural 
and  morbid,  and  by  the  adroit  employment  of  suitable  instruments. 

Inasmuch  as  the  general  treatises  upon  surgery,  as  well  as  the  most 
modern  writers  on  the  diseases  of  the  rectum,  are  almost  wholly  silent  upon 
this  important  point  in  the  diagnosis  of  rectal  diseases,  the  author  conceives 
that  it  will  not  be  out  of  place  to  indicate  the  rules  which  he  follows  in  ex- 
ploring this  portion  of  the  intestinal  canal,  and  to  give  different  methods  of 
performing  that  operation. 

A  correct  understanding  of  the  manner  of  introducing  the  sound,  bougie 
or  tube  into  the  rectum,  or  into  the  sigmoid  flexure  of  the  colon,  is  often  as 
important  to  the  safety  of  the  patient  as  is  the  passage  of  the  catheter  into 
the  bladder ;  yet,  as  before  observed,  it  is  scarcely  ever  mentioned  by  authors, 
and  is  certainly  not  included  in  the  catalogue  of  surgical  operations.  There- 
fore, taking  into  consideration  the  anatomical  relations  of  the  parts  con- 
cerned, the  construction  of  instruments  especially  adapted  to  the  purpose, 
and  the  various  obstacles  which  may  obstruct  their  passage,  together  with 
the  necessary  measures  of  overcoming  them,  it  is  obvious  that  the  subject 
demands  a  more  thorough  examination  than  has  yet  been  bestowed  upon  it. 
This  would  appear  to  be  the  more  particularly  called  for  at  this  special  junc- 
ture of  time,  when  nature,  in  other  departments  of  the  science,  is  being  sub. 
jected  to  so  much  a  severer  test  of  interrogation  than  has  ever  before  been 
adopted,  and  by  so  much  superior  and  more  thorough  methods  of  investiga- 
tion ;  and  more  especially,  too,  since  the  scope  of  medical  science  is  now 
daily  expanding,  and  an  inquisitive  public  anxiously  expecting  and  impa- 
tiently awaiting  the  establishment  and  exposition  of  its  unmystified  rational 
practice. 


IV  PREFACE. 

Although  the  labor  in  this  field  of  investigation  is  by  no  means  inviting 
and  pleasant,  but  rather  repulsive  and  distasteful,  yet  it  must  be  admitted  by 
all  to  be  highly  important  and  useful,  for  upon  it  the  life,  health,  comfort 
and  convenience  of  so  many  so  much  depend.  No  subject,  however,  should 
be  considered  undignified,  or  unworthy  of  anxious  attention,  which  involves 
such  serious  consequences,  or  which  has  for  its  object  the  improvement  of 
the  healing  art  or  the  extension  of  our  knowledge  of  nature's  operations. 
No  standard  is  known  by  which  to  determine  the  dignity  or  the  respectabil- 
ity of  any  branch  of  medicine,  than  its  capability  of  saving  life  and  suffering. 

The  ligation  of  haemorrhoidal  tumors,  the  subject  of  the  appendix, 
although  out  of  place  here,  should  nevertheless  attract  the  reader's  attention. 

It  may  seem  to  some  that  the  descriptions  in  this  work,  both  anatomical 
and  operative,  are  too  unnecessarily  minute  in  their  details  ;  but  the  author 
would  observe  to  such,  that  it  is  the  neglect  of  minuteness  and  the  fondness 
for  generalization  which  involve  a  subject  in  obscurity.  As  long  as  we  ad- 
here to  facts,  we  cannot  be  too  microscopical,  for  facts,  however  simple,  are 
as  essential  to  refute  opinions  as  they  are  to  establish  principles. 

Upon  some  points  it  will  be  seen  that  the  author  has  not  hesitated  to 
express  opinions  more  or  less  at  variance  with  those  of  surgeons  of  deservedly 
high  reputation  and  celebrity.  If,  however,  he  has  done  this  in  a  respectful 
manner,  no  just  exception  can  be  taken  and  no  apology  is  necessary. 

In  conclusion,  the  author  would  remark,  that  while  this  little  brochure 
does  not  profess  to  be  anything  more  than  an  introduction  to,  or  an  outline 
of  the  subject,  it  nevertheless  does  not  fail  to  include  the  most  salient  points. 
He  therefore  trusts  that  sufficient  has  been  presented  to  make  it  attractive 
and  useful,  especially  to  the  student  and  junior  practitioner,  to  whom,  with 
its  many  defects,  it  is  most  respectfully  addressed. 

837  FIFTH  AVENUE,  NEW  YORK,  July,  1870. 


TABLE   OF   CONTENTS. 


SECTION  I. 
INTRODUCTORY  REMARKS. 

PAGE 

The  ignorance  heretofore  on  the  subject  of  the  Diseases  of  the 
Rectum.  The  causes  of  this  ignorance  attributed  chiefly  to  the 
neglect  on  the  part  of  the  practitioner  to  make  a  proper  explora- 
tion of  the  organ,  and  the  great  disinclination  on  the  part  of  the 
patient  to  submit  to  such  examination.  These  causes,  to  a  con- 
siderable extent,  are  now  being  happily  removed.  .  .  .1-3 

SECTION  II. 
THE  ANATOMY  OF  THE  RECTUM. 

A  description  of  the  Rectum  only  so  far  as  it  relates  to  its  position  in 
the  pelvis  ;  its  commencement ;  its  termination ;  its  length  ;  its 
direction  ;  its  form  ;  its  capacity  ;  its  relations  ;  its  divisions  ;  its 
mucous  lining,  with  its  rugfe  or  folds.  The  columns  of  Morgagni. 
The  lacunae  of  the  Rectum.  Are  there  veritable  valves  of  the 
Rectum  ?  The  question  important  to  the  rectal  explorer.  The 
declarations  of  Cheselden,  Morgagni,  Portal,  Glisson,  Boyer,  Wil- 
son and  Horner  in  the  affirmative.  The  ingenious  hypothesis  of 
Mr.  Houston  to  establish  the  existence  of  such  valves.  The 
author  denies  their  existence  in  the  rectum. 


SECTION  III. 
PHYSICAL  EXPLORATION. 

The  diagnosis  in  the  diseases  of  the  Rectum  and  Anus  chiefly  deter- 
mined by  a  visual  and  a  tactile  examination.  The  proper  instru- 
ments to  be  employed.  Digital  and  specular  examination.  Pre- 
liminary steps  to  an  examination.  The  position  of  the  patient 
and  the  surgeon.  The  right  index-finger.  Palpation.  A  descrip- 
tion of  several  speculse  ani  and  the  new  instrument,  the  recto-colo- 
nic  endoscope.  Prof.  Storer  repudiates  the  speculum  ani  as  a 
means  of  diagnosis  in  the  rectal  diseases  of  females,  and  substi- 


VI  CONTENTS. 

PAOB 
tutes  rectal  eversion  for  it.     The  author  points  out  the  difficulties 

of  rectal  eversion,  and  shows  that  at  best  it  is  too  limited  in  extent 
to  dispense  with  the  anal  speculum.  Rupturing  the  sphincter 
ani,  as  a  means  of  diagnosis,  as  advised  by  Prof.  Storer.  The 
author  is  of  opinion  that  no  such  operation  is  ever  justifiable  for 
such  a  purpose,  inasmuch  as  the  great  capacity  of  the  anus  and 
anal  canal  naturally  for  dilatation  may  always  be  dilated  readily, 
speedily,  safely  and  sufficientlv  under  the  influence  of  anaesthet- 
ics or  belladonna,  without  inflicting  any  injury  whatever  upon 
the  integrity  of  the  parts.  Splanchnoscopy  by  translucency. 
Exploration  by  means  of  the  probe 19-31 

SECTION  IV. 
SOUNDING  THE  RECTUM. 

Description  of  the  instruments  used  in  sounding  the  Rectum.  The 
method  of  introducing  the  sound,  bougie  or  tube  into  the  rectum, 
and  sigiuoid  flexure  of  the  colon.  The  operation  divided  into 
four  stages.  The  particular  manipulation  in  each  stage.  Partic- 
ular directions  and  precautions  to  be  observed  in  sounding.  .  .  32-41 

APPENDIX. 

ON  THE  LlOATION  OP  H^EMORRIIOIDAL  TUMORS.  .   43-54 


THE 

PHYSICAL   EXPLORATION 

OF  THE 

IR,    IB    O    O?    TJ 


SECTION  I. 

INTRODUCTORY   REMARKS. 

Mr.  Lizars,  in  his  "  System  of  Surgery,"  very  correctly 
observes  that, — "  diseases  of  the  rectum  are  very  common,  very 
numerous  and  important ;  still,  however,  they  are  out  little 
understood"  Not  many  years  ago,  such  was  the  ignorance  on 
the  subject  of  some  of  those  diseases,  that  a  very  able  writer  in 
the  "  London  Medico-Chirurgical  Review  "  observed  that, — 
"  beyond  the  treatment  of  Fistula  in  Ano  and  Haemorrhoids, 
the  surgery  of  the  rectum  is  a  sort  of  land  of  the  Cimmerians, 
where  quacks  alone  can  breathe,  and  where  humbug  darkens 
the  air" 

But  are  not  the  diseases  of  the  rectum  just  as  susceptible  as 
any  others  of  exact  observation,  of  scientific  analysis,  and  of 
safe,  certain  and  appropriate  treatment  ?  Is  it  indeed  impossi- 
ble for  light  ever  to  dawn  upon  this  region,  said  to  be  darkened 
by  humbug  and  inhabited  alone  by  quacks  ? 

It  may  be  observed  that  the  ignorance  on  the  subject  of  the 
diseases  of  the  rectum,  which  had  so  long  prevailed,  and  which 
to  a  certain  extent  still  exists,  may  very  justly  be  attributed  to 
the  failure,  on  the  part  of  practitioners  generally,  of  making  a 
proper  exploration  of  this  organ.  The  rectum  heretofore  has 
been  a  terra  incognita  in  the  domain  of  surgery,  into  which 


THE    PHYSICAL    EXPLORATION    OF    THE    RECTI'M. 

the  practitioner  did  not  care  to  venture.  But  this  ignorance 
is  now  being  rapidly  dispelled,  and  this  organ  is  becoming  as 
subservient  to  the  laws  of  physical  exploration  as  any  other. 
The  surgery  of  the  rectum,  particularly  as  it  regards  its 
manipulative  branch,  has  made  rapid  strides  since  the  intro- 
duction of  anaesthetics.  These  and  the  now  common  use  of 
the  speculum  ani  and  rectal  endoscope  are  daily  revealing  the 
dark  and  the  hidden  mysteries  of  this  darksome  passage. 

Some  of  the  reasons,  however,  why  an  examination  of  the 
rectum  is  so  universally  omitted  are  obvious  enough.  Such  an 
inspection  is  not  a  very  pleasant  affair,  either  to  the  patient  or 
to  the  practitioner,  but  rather  more  or  less  repulsive  to  both. 
In  females,  too,  the  delicacy  of  the  sex  often  induces  them  to 
conceal  their  maladies  in  this  region,  and  throws  various  obsta- 
cles in  the  way  to  an  inspection  of  them  ;  yet,  if  the  practi- 
tioner consults  his  own  reputation  or  the  welfare  of  his  patient, 
he  will  insist  on  making  an  examination,  especially  when 
positive  symptoms  are  complained  of,  or  when  suspicious  ones, 
not  otherwise  well  accounted  for,  do  exist.  The  surgeon 
should  never  prescribe  for  affections  of  the  rectum  and  anus 
without  a  proper  visual  and  tactile  inquiry  into  their  real 
character.  I  have  often  witnessed  the  folly  and  the  mischief 
arising  from  the  practice  of  prescribing  for  supposed  or  im- 
aginary complaints,  the  product  of  the  patient's  own 
judgment  or  imagination,  the  real  nature  of  which  might 
have  been  readily  discovered  by  a  proper  examination  of  the 
parts  concerned.  Patients  most  always  call  their  maladies  in 
this  locality — piles  /  indeed,  all  the  various  affections  of  the 
rectum  and  anus  are  generally  so  denominated  by  them.  The 
surgeon,  however,  should  not  copy  the  errors  of  his  patient  in 
this  respect,  to  believe  without  evidence  or  conviction,  which, 
if  he  does,  will  assuredly  lead  him  to  prescribe  for  diseases 
which  exist  only  in  the  conjoint  imagination  of  both. 

It  is,  doubtless,  owing  to  these  several  causes  that  so  many 
patients  suffering  from  these  affections  have  heretofore  fallen 
into  the  hands  of  empirical,  unprincipled  and  reckless  practi- 
tioners, whose  deceptions  were  favored  by  the  locality  of  the 
disease,  and  who  were  thus  encouraged  and  emboldened  to 
continue  to  practice  their  impositions  with  impunity.  Indeed, 
it  may  truly  be  said  that  the  general  ignorance  which  pre- 


THE  PHYSICAL  EXPLORATION  OF  THE  RECTI'M.         S 

vailed  in  the  profession  with  regard  to  those  diseases,  and  the 
locality  of  them,  furnished  the  ignorant  pretender  with  an 
almost  inaccessible  asylum.  But,  as  before  observed,  this 
ignorance  of  the  subject,  and  this  repugnance  to  making  or 
submitting  to  a  rectal  examination,  are  now  being  rapidly  dis- 
pelled. 

From  the  preceding  considerations,  it  is  of  the  utmost  im- 
portance, as  a  general  rule,  that  a  careful  and  minute  explora- 
tion of  the  rectum  and  anus  should  be  made,  as  a  preliminary 
step  to  the  treatment  of  the  diseases  of  these  organs,  the  diag- 
nosis of  some  of  which  is  often  so  very  obscure.  This  examina- 
tion, too,  should  not  be  long  delayed,  for,  by  the  neglect  of 
this  precaution,  an  aifection  which,  if  timely  attended  to, 
would  readily  yield,  is  suffered  to  make  progress  and  to  become 
difficult  of  cure. 


SECTION  II. 

THE   ANATOMY   OF   THE   RECTUM. 

1.  A  knowledge  of  the  anatomy  of  the  rectum  is  an  essen- 
tial prerequisite  to  the  successful  exploration  of  the  same.  I 
will  here,  however,  only  give  a  description  of  this  intestine  so 
far  as  it  relates  to  its  position  in  the  pelvis ;  its  commence- 
ment ;  its  termination  ;  its  length  ;  its  direction  ;  its  form  ;  its 
capacity ;  its  relations  ;  its  divisions,  and  the  rugae  or  folds  of 
its  mucous  lining. 

That  portion  of  the  alimentary  canal  which  has  obtained  the 
appellation, — rectum,  occupies  the  posterior  part  of  the  pelvis, 
and  is  continuous  with  the  sigmoid  flexure  of  the  colon  (Fig.  1). 


[A  view  of  the  Rectum,  together  with  the  position  and  curvatures  of  the  colon.  1.  The 
ilenm  terminating  in  the  caecum.  2.  The  appendicula  vermiformis.  3.  The  caecum.  4. 
The  ascending,  or  right  lumbar  colon.  5.  The  transverse  colon,  or  arch  of  the  colon.  6. 
The  descending,  or  left  lumbar  colon.  7.  The  iliac  colon,  or  sigmoid  flexure  of  the  colon. 
8.  The  rectum.  9.  The  pouch  of  the  rectum.  10.  The  anus.] 


THE    PHYSICAL    EXPLORATION    OF    THE    RECTUM. 


5 


It  commences  at  a  point  horizontal  with  and  quite  contiguous 
to  the  left  ilio-sacral  symphysis,  and  it  terminates  at  the  anus. 
Its  length  in  full  grown  subjects,  taking  the  standard  of  the 
human  body  at  from  five  feet  eight  inches  to  five  feet  ten 
inches,  is  about  eleven  inches.  The  rectum,  however,  is 
neither  of  uniform  length  nor  caliber,  as  the  following  admeas- 
urements I  made  of  it  in  the  dead  bodies  of  eight  adult  sub- 
jects will  show.  The  organ  in  each  of  these  instances  was 
carefully  examined  whilst  in  situ.  In  these  cases,  if  the  rec- 
tum had  been  detached  from  its  natural  situation  in  the  pelvis 
and  dilated,  a  very  different  result  would,  doubtless,  have 
been  obtained. 

The  following  table,  giving  the  results  which  I  obtained, 
presents  the  age  of  the  subject,  the  sex,  the  whole  length  of 
the  rectum,  the  diameter  at  its  commencement  and  at  the 
bottom  of  its  pouch,  immediately  above  the  superior  margin  of 
the  internal  sphincter  of  the  anus  : — 


TABLE. 


CO 

5" 

E. 

H 

Length 
of 

Diameter 
at 

Diameter 
at 

a 

CD 

I 

Rectum. 

Commencement. 

Bottom  of  Pouch. 

i 

21 

F 

11  Inches  and    5  Lines. 

1  Inch  and    5  Lines. 

1  Inch  and  10  Lines. 

2 

28 

M 

11  Inches  and  11  Lines. 

1  Inch  and    9  Lines. 

1  Inch  and  11  Lines. 

3 

47 

M 

12  Inches  and  —  Lines. 

1  Inch  and   8  Lines. 

1  Inch  and  11  Lines. 

4 

40 

F 

10  Inches  and  11  Lines. 

1  Inch  and   2  Lines. 

1  Inch  and   9  Lines. 

5 

60 

M 

12  Inches  and    2  Lines. 

1  Inch  and  10  Lines. 

2  Inches  and  3  Lines. 

6 

55 

M 

12  Inches  and    3  Lines. 

1  Inch  and  11  Lines. 

2  Inches  and  1  Line. 

7 

35 

M 

11  Inches  and   9  Lines. 

1  Inch  and  10  Lines. 

1  Inch  and  10  Lines. 

8 

45 

F 

11  Inches  and   8  Lines. 

1  Inch  and   7  Lines. 

2  Inches  and  5  Lines. 

The  form  of  the  rectum  is  cylindrical  at  its  commencement, 
and  indeed  throughout  a  considerable  portion  of  its  extent ; 
but  towards  its  inferior  extremity,  however,  it  becomes  large 
and  saccated,  forming  a  terminal  pouch,  which  is  dilated  and 
flattened  from  before  backward,  and  the  mouth  of  which  is 
closed  by  the  internal  sphincter  muscle,  like  a  purse.  The 
size  of  the  rectum  for  some  distance  is  nearly  continuous  with 
that  of  the  sigmoid  flexure  of  the  colon  ;  but  it  differs  from  the 
other  portions  of  the  intestines  by  its  becoming  wider  in.  its 
downward  progress,  until  it  reaches  the  superior  margin  of  the 


fi  THE    PHYSICAL    EXPLORATION    OF    THE    RECTUM. 

internal  sphincter  muscle.     From  its  commencement  on  the 
left  side,    at  the    superior    opening   of  the  pelvis   (Fig.    2), 

FIG.  2. 


[A  side  view  of  the  pelvic  viscera  of  the  male  in  their  normal  situation.  1.  The  divided 
surface  of  the  pubic  bone.  2.  The  divided  surface  of  the  sacrum.  3.  The  body  of  the  blad- 
der. 4.  Its  fundus,  with  the  urachus  at  its  apex.  5.  The  base  of  the  bladder.  6.  The 
ureter.  7.  The  neck  of  the  bladder.  8.  The  pelvic  fascia.  9.  The  prostate  gland.  10.  The 
membranous  portion  of  the  urethra.  11.  The  triangular  ligament  formed  of  two  layers. 
12.  One  of  Cowper's  glands.  13.  The  bulb  of  the  spongy  body.  14.  The  body  of  the 
spongy  structure.  15.  The  right  leg  of  the  penis.  16.  The  upper  part  of  the  superior  por- 
tion of  the  rectum.  17.  The  recto-vesical  fold  of  the  peritonaeum.  18-  The  central  or  middle 
portion  of  the  rectum.  19.  The  right  seminal  vesicle.  20.  The  deferent  duct.  21.  The 
rectum  covered  by  the  descending  layer  of  the  pelvic  fascia.  22.  A  part  of  the  elevator 
muscle  of  the  anus.  23.  The  external  sphincter  ani.  24.  The  interval  between  the  deep 
and  superficial  perinieal  fascia.  25.  The  anus.] 

it  is  directed  from  above  downward,  and  at  first  a  little 
obliquely  from  left  to  right,  descending  into  the  pelvis  along 
the  anterior  surface  of  the  sacrum  for  about  six  inches,  occa- 
sionally undergoing,  in  some  subjects,  slight  lateral  inflections, 
until  it  has  arrived  at  the  median  line  of  the  body,  at  a  point 
opposite  the  junction  of  the  third  and  fourth  bone  of  the 
sacrum ;  adapting  itself,  during  its  downward  course,  to  the 
curvature  of  the  bone  over  which  it  has  to  pass.  From  this 
point  it  is  then  directed  obliquely  from  above  downward, 
and  from  behind  forward,  for  about  four  inches,  still  in  the 
median  line,  to  the  extremity  of  the  coccyx,  arid  on  a  level 
with  the  prostate  gland.  Finally,  from  immediately  below  the 
level  of  the  prostate  gland,  it  is  directed  obliquely  from  above 


THE    PHYSICAL    EXPLORATION    OF    TIIK    RKCTI'At.  i 

downward,  and  a  little  from  before  backward,  for  about  one 
inch  and  a  half,  to  terminate  at  the  amis. 

2.  Divisions  of  tJtv  Iteciwm. — The  rectum,  for  better  eluci- 
dation, may  be  distinguished  into  three  divisions  : — a  superior, 
a  central,  and  an  inferior  ;  the  three  main  curvatures  which 
the  organ  describes,  in  its  downward  course,  being  made  the 
foundation  of  these  natural  divisions.  (Fig.  3.)  Each  division 

FIG.  3, 


[A  side  view  of  the  viscera  of  tho  female  pelvis  in  their  natural  situation.  1.  The  ^ym- 
physis  pubis.  2.  The  abdominal  parietes.  3.  The  fat  forming  the  mon*  veneris.  4.  The 
bladder.  5.  The  entrance  of  the  left  ureter.  6.  The  canal  of  the  urethra.  7.  The  nieatus 
urinarious.  8.  The  clitoris  and  its  prepuce.  9.  The  left  nympha.  10.  The  left  labium. 
11.  The  orifice  of  the  vagina.  12.  Its  canal  and  transverse  rug*.  13.  The  vesico- vaginal 
septum.  14.  The  vagino-rectal  septum.  15.  Section  of  the  perin.eum.  1(5.  The  os  uteri. 
17.  The  cervix  uteri.  18.  The  fundus  uteri.  19.  The  rectum.  20.  The  anus.  21.  The  su- 
perior portion  of  the  rectum.  22.  The  central  or  middle  portion  of  the  rectum.  23.  The 
inferior  portion  of  the  rectum.  24.  The  peritomeum  reflected  on  the  bladder  from  the  ab- 
dominal parietes.  25.  The  last  lumber  vertebra.  26.  The  sacrum.  27.  The  promontory  of 
the  sacrum.  28.  The  coccyx.] 

is  distinct  in  its  situation,  structure,  and  in  the  nature  and  im- 
portance of  its  connections  with  regard  to  the  several  organs 
in  the  pelvic  cavity.  Their  several  relations  vary  in  the  two 
sexes,  and  a  complete  knowledge  of  which  is  of  the  highest 
importance  in  a  surgical  point  of  view.  (See  Figs.  2,  3.) 

The  Superior  Portion, — This  portion  of  the  rectum  extends 
from  the  commencement  of  this  organ,  at  the  inferior  extrein- 


8  THE    PHYSICAL    EXPLORATION    OF    THE    RECTUM. 

itj  of  the  sigmoid  flexure  of  the  colon,  to  the  junction  of  the 
third  and  fourth  bone  of  the  sacrum,  just  where  the  organ 
leaves  its  peritonaeal  investment  to  curve  below  the  bladder. 
It  is  about  six  inches  long,  being  the  largest  portion,  and  about 
half  the  length  of  the  whole  ^organ  itself.  In  its  direction 
downward,  as  has  already  been  noticed,  it  describes  a  curve, 
the  convexity  of  which  is  turned  backward,  and  corresponds 
to  the  sacrum.  Anteriorly  it  corresponds  to  the  posterior  sur- 
face of  the  bladder  in  the  male,  and  to  the  uterus  and  a  small 
portion  of  the  vagina  in  the  female,  and  in  both  sexes  to  a  fold 
of  the  ileum,  lodged  in  the  intervening  cul-de-sac.  It  is  tor- 
tuous, smooth  and  loosely  attached  to  the  left  half  of  the  ante- 
rior surface  of  the  sacrum  by  a  short  fold  of  the  peritonaeum, 
the  meso-rectum.  This  portion  of  the  rectum  might,  with 
great  propriety,  be  termed  the  peritonceal  portion,  because  of 
its  being  completely  invested  by  this  membrane. 

The  Central  Portion. — This  portion  commences  where  the 
rectum  leaves  its  peritonaeal  envelop,  and  begins  to  pass  below 
the  bladder.  It  is  about  four  inches  long,  and  its  direction  is 
obliquely  from  above  downward,  and  from  behind  forward, 
slightly  curving  in  the  same  direction,  the  convexity  bearing 
upward.  It  is  fixed  and  immovable,  and  always  corresponds 
anteriorly  to  the  vagina  in  the  female ;  and  in  the  male  to  a 
small  portion  of  the  posterior  part  of  the  bladder,  from  which 
it  is  separated  downward  and  outward  by  the  seminal  vesicles 
and  vassa  deferentia,  and  lies  in  close  relation  with  them. 
Towards  its  termination  it  corresponds  to  the  prostate  gland 
and  the  commencement  of  the  membranous  portion  of  the 
urethra,  and  is  in  contact  with  them.  In  the  female  it  is  very 
intimately  and  firmly  connected  to  the  vagina  by  a  vascular 
network  constituting  the  recto-vaginal  septum ;  but  in  the 
male  it  is  but  loosely  connected  to  the  base  of  the  bladder  and 
prostate  gland  by  a  layer  of  cellular  tissue  of  a  soft  and  lax 
character.  It  differs  quite  materially  in  its  organization, 
structure  and  attachments  from  the  superior,  or  free  portion, 
and  being  destitute  of  the  peritonaeal  covering,  except  a  small 
portion  on  the  upper  part  of  its  anterior  face,  over  which  the 
peritonaeum  is  sometimes  extended  when  the  bladder  is  empty. 

The  Inferior  Portion. — This  portion  of  the  rectum  com- 
mences at  the  extremity  of  the  coccyx,  and  terminates  at  the 


THE    PHYSICAL    EXPLORATION    OF   THE    RECTUM.  9 

anal  orifice.  Its  length  is  about  one  inch  and  a  half,  and  its 
direction  is  obliquely  downward  and  backward.  This  last  in- 
flection separates  it  from  the  urethra  in  the  male,  and  from  the 
vagina  in  the  female.  It  is  of  greater  capacity  above  than 
below,  and  is  surrounded  by  dense  adipose  cellular  tissue,  ex- 
cept at  its  upper  extremity  in  front,  where  it  is  closely  attached 
to  the  prostate  gland.  In  its  lower  three-fourths  it  is  com- 
pletely invested  by  the  sphinctores  ani.  This  portion  of  the 
rectum  might,  with  great  propriety,  be  termed  the  anal  por- 
tion, or  anal  canal. 

3.  The    Mucous   M&mbrcme.     The   mucous   tunic   of  the 
rectum  is  quite  redundant  in  every  direction,  but  especially 
so  in  the  superior  portion ;  -as  it  approaches  the  inferior  por- 
tion, however,  it  begins  to  lose  this  redundancy  to  a  consider- 
able extent,  and  this  is  most  evident,  in  its  circular  direction. 
In  consequence  of  its  great  amplitude,   it  is,  when  not  dis- 
tended, disposed  into  irregular  undulating  plicae  which  usually 
assume   a   transverse   direction.     It   is   sometimes,   however, 
thrown  into  distinct  ridges,  which  observe  a  slightly  oblique 
and   circular   direction,  resembling   very  much   the  valvulse 
conniventes  of  the  small  intestines.    This  corrugated  condi- 
tion of  the  mucous  coat  of  the  rectum  is  purely  accidental  and 
caused  by  muscular   contraction,  since  there  are   no  valves 
naturally  furnished    this    organ.     The   duplications  are   not 
permanent  and  may  be  entirely  effaced  by  distention.    They 
neither   observe  any  regular  form,  any  regular  number,  nor 
always  any  particular  situation  or  direction. 

4.  Columns  of  the  Rectum.     The  mucous  coat  of  the  rectum 
after  having  presented  itself  in  transverse  folds,  as  has  already 
been  observed,  begins  immediately  above  the  superior  margin 
of  the  internal  sphincter  of  the  anus,  to  display  itself  in  par- 
allel longitudinal  folds,  which  stand  out  or  project  in  such  a 
remarkable  manner,  as  to  have  obtained  from  Morgagni  the 
appellation  columns  or  pillars  of  the  rectum,  hence  they  are 
termed  by  the  French — "  colonnes  dii  rectum  on  de  Morgagni ." 
(Dictionnaire    de   Medicine   et  CMrurgie,  p.  701.     Paris, 
1845.) 

These  duplicatures  are  not  so  numerous  and  so  irregular  as 


to 


THE    PHYSICAL    EXPLORATION    OF    THE    KECTUM. 


the  transverse  and  oblique,  nor  as  the  radiated  folds  of  the  ex- 
ternal integument  at  the  anus.  Their  dimensions  are  unequal, 
and  they  vary  in  number  from  four  to  ten  or  twelve,  and  when 
they  are  more  numerous  some  of  them  are  rudimentary. 
Their  number  and  position,  to  a  considerable  extent,  appear 
to  be  fixed,  by  the  peculiar  terminal  arrangement  of  the  longi- 
tudinal muscular  fibres.  They  diner  from  the  other  mucous 
folds  of  the  rectum,  by  being  formed  of  the  mucous,  as  well  as 
of  the  adjacent  cellular  tissue  and  the  longitudinal  muscular 
fibres,  which  give  them  additional  density  and  strength ;  by 
their  not  being  alone  the  result  of  muscular  contraction  ;  and 
by  their  not  being  capable  of  entire  obliteration  by  distention. 
These  columnce  after  entering  the  anal  canal  and  proceeding 
downwards,  diminish  in  size  and  terminate  rather  abruptly  in 
rounded  extremities  just  above  the  inferior  margin  of  the  inter- 
nal sphincter  of  the  anus.  They  somewhat  resemble  the  lon- 
gitudinal duplications  of  the  ossophagus. 


FIG.  4. 


[A  vertical  section  of  the  parietes  of  the  rectum,  showing  the  bases  of  the  columns  of 
Morgagni,  and  the  lacunae  or  sacculi  of  the  rectum.  1.  The  bases  of  the  columns.  2.  The 
lacunae.] 

5.  Lacunce  of  the  Rectum.  (Fig.  4.)  In  the  sulci  formed  by 
the  columns  of  the  rectum,  another  arrangement  of  the  mucous 
coat  takes  place,  which  is  always,  however,  most  remarkable 
at  the  termination  of  the  sulci  immediately  below  the  inferior 
margin  of  the  internal  sphincter  ani.  At  this  point  membra- 
nous folds,  more  or  less  numerous,  of  a  semi-lunar  form,  present 
themselves,  their  number  corresponding  to  that  of  the  grooves 


THE   PHYSICAL    EXPLORATION    OF   THE   RECTUM.  11 

themselves,  and  their  direction  being  usually  transverse,  though 
sometimes,  but  rarely,  oblique.  These  folds,  occurring  as  they  do, 
at  the  lower  end  of  the  grooves,  and  between  the  columns,  have 
each  of  their  ends  attached  to  the  base  of  one  of  these  columns, 
and  their  free  and  curving  margins  directed  from  below  up- 
ward, thus  forming  a  series  of  narrow  semi-lunar  lacunae  or  pits, 
varying  in  depth  from  one  to  four  lines,  and  the  orifices  of 
which  presenting  upward,  whilst  their  bottoms  are  directed 
downward.  These  lacunae  or  sacculi  always  contain  more  or 
less  mucus  furnished  them  by  the  glands  of  the  vicinity,  and 
ready  to  be  poured  out  for  the  lubrication  of  the  lower  portion 
of  the  anal  canal,  whenever  they  are  compressed  by  the  act  of 
extruding  the  fecal  matter.  Distention  of  the  canal  com- 
presses them,  but  it  does  not  entirely  obliterate  them.  By 
pressing  them  firmly  at  any  time,  a  little  viscid  mucus  may  be 
seen  to  issue  from  them.  They  have  certain  physiological  and 
pathological  relations  which  are  not  necessary  to  notice  here. 

The  existence  of  these  lacunas  or  sacs  in  the  lower  portion 
of  the  anal  canal,  has  at  an  early  day,  been  recognized  by  some 
of  the  old  anatomists.  Astruc  says  that, — "  In  the  margin  of 
the  anus  itself,  several  short  ducts,  or  rather  lacunae  appear 
which  convey  a  viscid  humour."  (A  Treatise  on  the  Fistula 
of  the  Anus,  p.  6.  London,  1738.)  Winslow  also  notices  them 
in  the  following  concise  manner : — "  Near  the  extremity  of  this 
intestine  (rectum)  the  rugae  or  folds  become  in  a  manner  lon- 
gitudinal and  at  last,  towards  the  circumference  of  the  inner 
margin  of  the  anus,  they  form  little  bags,  or  semi-lunar  lacunae, 
the  openings  of  which  are  turned  upward  toward  the  cavity  of 
the  intestine.  These  lacunae  are  sometimes  like  those  at  the 
lower  extremity  of  the  ossophagus,  or  upper  orifice  of  the 
stomach."  (An  Anatomical  Exposition  of  the  Structure  of  the 
Human  Body.  English  translation.  By  G.  Douglas,  M.  D., 
Vol.  IL,  p.  148.  London,  1732.)  Cruveilhier  also  mentions 
these  lacunae.  He  says  that, — "  The  point  at  which  it  (the 
skin)  becomes  continuous  with  the  mucous  membrane  is  de- 
serving of  notice ;  it  is  within  the  rectum,  at  the  distance  of 
some  lines  from  the  anus  properly  so  called,  and  is  marked  by  a 
waved  line,  which  forms  a  series  of  arches,  or  festoons,  having 
their  concavities  directed  upward.  Sometimes  there  are  small 
pouches  in  the  situation  of  these  arches  opening  upward. 
2 


12       THE  PHYSICAL  EXPLORATION  OF  THE  KKOTUM. 

From  the  angles  at  which  the  arches  unite,  some  mucous  folds 
proceed,  and  small  foreign  bodies  detached  from  the  fteces,  are 
often  retained  in  the  cul-de-sac,  and  become  the  causes  of  fis- 
tulas." (The  Anatomy  of  the  Human  Body.  Translated  by 
G.  8.  Pattison,  M.  D.,  p.  380.  New  To/A,  1844.)  H. 
Cloquet  also  describes  these  lacunae  very  correctly.  He  says, 
— "  Entre  ces  colonnes,  il  existe  presque  constamment  des 
replis  semi-lunaires  membraneux,  plus  ou  moins  nombreux 
obliques  ou  transverses,  dont  le  bord  est  diringe  de  bas  en 
haut  du  cote  de  la  cavite  de  I'intestin.  Ces  replis  forment  des 
aspeces  de  lacunes  dont  le  fond  est  etroit  et  tourne  en  bas." 
(Traite  d?Anatomie,  tome  II. ,  p.  343.  Paris,  1822.)  John 
Bell,  doubtless,  alludes  to  these  lacunae,  under  the  phrase, 
notched-like  irregularities,  when  he  says, — "  Towards  the  anus 
the  folds  become  longitudinal,  and  terminate  in  the  notched- 
like  irregularities  of  the  margin."  ( The  Anatomy  and  Physi- 
ology of  the  Human  Body.  Vol.  III.,  p.  234.  New  York, 
1817.)  Horner  also  describes  them.  He  says, — "  At  the 
lower  end  of  the  wrikles,  between  the  columns  are  small 
Jxmches  of  from  two  to  four  lines  in  depth,  the  orifices  of 
which  point  upwards ;  they  are  occasionally  the  seat  of  disease, 
and  produce  when  enlarged,  a  painful  itching."  (Op.  tit.,  p. 
47.)  Some  anatomists  have  failed  to  discover  these  lacunas, 
and,  consequently,  have  concluded  that  they  do  not  exist.  In 
the  numerous  examinations  I  have  made  of  the  lower  end  of 
the  rectum,  I  have  never  failed  to  observe  them.  I  have 
generally  found  them  more  fully  developed  in  the  negro,  and 
to  be  larger  and  more  open  in  the  dog  and  in  the  rabbit. 
They,  doubtless,  are  normal  and  constant. 

6.  Are  there  Veritable  Valves  in  the  Rectum  f  I  must  here 
observe  that  a  question  of  no  small  importance  to  the  rectal 
explorer  has  arisen  among  eminent  anatomists  respecting  the 
existence  or  non-existence  of  valves  in  this  organ.  The  pecu- 
liar valve-like  arrangement  of  the  mucous  membrane  of  the 
rectum,  already  mentioned,  has  led  some  anatomists  to  infer 
and  to  endeavor  to  prove  that  there  are  veritable  valves  in 
this  as  in  the  small  intestines.  Cheselden  among  the  old 
anatomists  alludes  to  valves  in  this  organ.  When  speaking  of 
valves  in  the  colon,  he  says, — "  but  as  the  gut  approaches  the 


THE    PHYSICAL    EXPLORATION    OF   THE    RECTUM.  13 

anus,  they  (the  valves)  become  less  remarkable  and  fewer  in 
number."  (Anatomy  of  the  Human  Body,  p.  159.  London, 
1778.)  Morgagni  observes  that  he  found  valves  in  two  sub- 
jects, situated  about  a  finger's  breadth  above  the  anus.  The 
form  of  the  valves  in  one,  he  says,  was  circular,  and  in  the 
other  transverse.  (Adversaria  Anatomica  HI.  Animad- 
versio  VI.,  p.  10.  Lungduni  Batavorum,  1723.)  Portal  also 
speaks  of  these  folds  in  the  following  language : — "  Mais  on 
remarque  a  son  extremite  inferieure  pres  de  1'anus,  divers 
replis  de  sa  lame  interne,  lequels  forrnent  des  especes  de  valvu- 
les  rangees  a  peu  pres  circulairement.  Glisson,  qui  les  a 
reconnues,  les  nomment  les  valvules  semi-lunaires.  La  mem- 
brane interne  qui  constitue  ces  replis  se  relache  et  se  prolonge 
quelquefois  au  point  de  former  un  bourlet  qui  s'oppose  a  la 
sortie  des  excrements."  (Cours  d' 'Anatomie  Medicale. 
Paris,  1803.)  The  idea  of  calling  these  small  folds  valves, 
and  then  of  their  becoming  relaxed  and  prolonged,  except  in  a 
diseased  state,  so  as  to  form  a  barrier  or  an  obstruction  to  the 
passage  of  the  faeces,  is,  to  say  the  least  of  it,  hypothetical.  If 
ever  such  cases  occur,  they  must  be  rare  indeed.  M.  Boyer 
seems  to  verify  the  description  of  Portal.  He  says, — "  Quel- 
quefois mais  rarement,  au  lieu  des  replis  semi-lunaires  dont  il 
vient  d'etre  parle,  on  trouve  de  veritables  valvules  qui  bouchent 
en  quelque  sort  1'extremite  inferieure  du  rectum."  (Traite 
d'Anatomie,  tome  IV., p.  377.  Paris,  1815.)  Wilson  says, 
— "  In  the  csecum  and  colon  the  mucous  membrane  is  smooth, 
but  in  the  rectum  it  forms  three  valvular  folds,  one  of  which 
is  situated  near  the  commencement  of  the  intestine ;  the  second 
extending  from  the  side  of  the  tube,  is  placed  opposite  the 
middle  of  the  sacrum  ;  and  the  third  proceeding  from  the 
front  of  the  cylinder  is  situated  opposite  the  prostate  gland." 
(The  Dissector.  Edited  ly  P.  B.  Goddard,  M.  D.,  p.  52. 
Philadelphia,  1844.)  Horner  says  that, — "  At  a  correspond- 
ing part  on  each  side  of  the  gut  in  its  interior,  exists  a  trans- 
verse doubling  of  the  mucous  membrane,  forming  the  valvula 
connivens  alluded  to.  The  result  of  this  arrangement  is  a 
semi-circular  valve  on  each  side,  one  above  the  other,  the  mar- 
gins or  diameters  of  which  pass  each  other,  in  the  empty  and 
contracted  state  of  the  rectum,  but  touching  at  the  same  time, 
and  they  present  an  additional  barrier  to  the  involuntary 


14  THE    PHYSICAL    EXPLORATION    OF    THE    RECTUM. 

evacuation  of  faeces."  (Special  Anatomy  and  Histology,  Vol. 
II.,  p.  47.  Philadelphia,  1851.)  Meckel  speaks  of  several 
kind  of  fishes  which  present  very  analogous  transverse  folds  or 
valves,  as  he  terms  them.  He  says  they  are  often  very  numer- 
ous and  occupy  the  end  of  the  intestinal  canal.  (JDeutsckes 
Archiv  fur  die  Physiologic,  Band  TIL,  II.  11.) 

The  first  anatomist,  however,  who  called  especial  attention 
to  a  valvular  arrangement  of  the  rectum  was  Mr.  John  Hous- 
ton, of  Dublin,  curator  of  the  Museum,  and  one  of  the  demon- 
strators in  the  school  of  the  College  of  Surgery  in  Ireland. 
This  he  did  in  a  very  able  practical  paper,  entitled  "  Observa- 
tions on  the  Mucous  Membrane  of  the  Rectum,"  inserted  in 
the  fifth  volume  (1830)  of  the  Dublin  Hospital  Reports. 

Mr.  Houston  states  that  the  tube  of  the  rectum  does  not 
form,  as  is  generally  conceived,  one  smooth  uninterrupted 
passage,  it  is  on  the  contrary,  made  uneven  in  several  places 
by  valvular  projections  of  its  mucous  membrane,  standing 
across  the  passage.  In  a  physiological  point  of  view,  he  con- 
siders that  these  valvular  projections  are  necessary  to  support 
the  weight  of  faecal  matter,  and  prevent  its  urging  towards 
the  anus  and  exciting  a  sensation  demanding  its  discharge. 
Viewed  pathologically,  he  believes  that  they  explain  the  resist- 
ance given  to  the  introduction  of  bougies  :  that  their  arrange- 
ment indicates  the  necessity  of  employing  a  spiral-shaped, 
instead  of  a  straight  bougie ;  that  they  may  possibly  become 
the  most  frequent  seat  of  stricture  ;  that  they  have  often  been 
mistaken  for  strictures,  and  by  leading  to  the  frequent  practice 
of  bougies,  have  brought  on  the  very  malady  intended  to  be 
removed  ;  that  they  have  been  entirely  overlooked  by  all 
authors  who  have  treated  of  diseases  of  the  rectum,  and  have 
only  been  cursorily  alluded  to  by  M.  Cloquet  and  some  other 
anatomical  writers,  &c. 

After  stating  that  there  are  usually  three  or  four  of  these 
valves,  Mr.  Houston  proceeds  to  describe  them  as  follows : — 
"  The  position  of  the  largest  and  most  regular  valve  is  about 
three  inches  from  the  anus,  opposite  the  base  of  the  bladder. 
The  fold  of  next  most  frequent  existence  is  placed  at  the  upper 
end  of  the  rectum.  The  third  in  order  occupies  a  position 
about  midway  between  these,  and  the  fourth,  or  that  most 
rarely  present,  is  attached  to  the  side  of  the  gut,  about  one  inch 


THE    PHYSICAL    EXPLORATION    OF    TUB    KECTUM.  15 

above  the  anus.  In  addition  to  these  valves,  of  tolerably  reg- 
ular occurrence,  there  are  frequently  several  intermediate 
smaller  ones,  but  which  from  their  trifling  projection  and  want 
of  regularity  in  their  situation,  merit  comparatively  little 
notice. 

"  The  form  of  the  valves  is  semi-lunar  ;  their  convex 
borders  are  fixed  to  the  sides  of  the  rectum,  occupying  in  their 
attachments  from  one-third  to  one-half  of  the  circumference  of 
the  gut.  Their  surfaces  are  sometimes  horizontal,  but  more 
usually  they  have  a  slightly  oblique  aspect,  and  their  concave 
floating  margins,  which  are  defined  and  sharp,  are  generally 
directed  a  little  upwards.  The  breadth  of  the  valves  about 
their  middle,  varies  from  a  half  to  three-quarters  of  an  inch 
and  upwards,  in  the  distended  state  of  the  gut.  Their  angles 
become  narrow,  and  disappear  gradually  in  the  neighboring 
membrane.  Their  structure  consists  of  a  duplicature  of  the 
mucous  membrane,  enclosing  between  its  laminae  some  cellular 
tissue,  with  a  few  circular  muscular  fibres. 

"  The  relative  position  of  the  valves,  with  respect  to  each 
other,  deserves  attention.  That  situated  opposite  the  base  of 
the  bladder,  most  commonly  projects  from  the  anterior  wall  of 
the  gut ;  the  valve  next  above  from  the  left,  and  the  upper- 
most from  the  right  wall  ;  that  near  the  anus,  which  is  of  least 
frequent  occurrence,  occupies  a  place  when  present  towards 
the  left  and  posterior  wall.  Many  deviations  from  these  stated 
points  of  attachment  for  the  folds  will  be  found  to  occur,  but 
the  arrangement  is  nevertheless  always  such,  as  to  form  by 
their  being  placed  successively  on  different  sides  of  the  gut,  a 
sort  of  spiral  tract  down  its  cavity. 

"  In  regard  to  the  sacculated  form  which  the  rectum  ac- 
quires by  the  presence  of  these  valves,  the  gut  resembles  some- 
what the  colon  in  the  condition  of  its  interior,  but  in  the  pecu- 
liar spiral  arrangement  of  the  valves,  it  bears  more  an  analogy 
to  the  large  intestine  of  some  of  the  lower  animals,  in  which, 
as  for  example,  the  caecum  of  the  rabbit,  the  large  intestine  of 
the  serpent  and  dog-fish,  a  continuous  spiral  membrane  traverses 
the  cavity  from  end  to  end,  and  gives  to  the  alimentary  matters 
a  protracted  winding  course  towards  the  anus." 

Mr.  Houston  further  remarks, — "My  attention  was  first 
called  to  these  valves  by  preparations  which  I  made  to  demon- 


16  THE    PHYSICAL    EXPLORATION    OF    THE    RECTUM.  * 

strate  the  relative  situation  of  the  pelvic  viscera,  and  to  display 
the  natural  state  of  their  cavities ;  and  from  the  manner  in 
which  the  making  of  these  preparations  was  conducted,  viz.  : 
— by  distending  and  hardening  all  the  parts  with  spirit,  pre- 
viously to  being  cut  open,  the  valvular  condition  above  alluded 
to,  was  most  satisfactorily  exhibited."  He  further  says, — 
"  This  is  the  only  method  by  which  the  condition  of  these 
valves  in  the  distended  state  of  the  rectum  can  be  displayed," 
and  that  "  by  the  ordinary  procedure  of  extending  it,  after  re- 
moval from  the  body,  the  valves  are  made  to  disappear." 
Again,  speaking  of  these  so-called  valves,  he  says, — "  Their 
presence  may  likewise  be  ascertained  in  the  empty  state,  if 
looked  for  soon  after  death,  and  before  the  tonic  contraction  of 
the  gut  has  subsided.  They  will  then  be  found  to  overlap 
each  other  so  effectually,  as  to  require  a  considerable  man- 
oeuvre in  conducting  a  bougie  or  the  finger  along  the  cavity  of 
the  intestine." 

I  have  quoted  quite  sufficient  from  this  ingenious  author  to 
present  him  fairly,  and  I  hesitate  not  to  say  at  once  that  in  my 
opinion  he  has  entirely  failed  to  establish  the  verity  of  his 
statements,  that  the  folds  or  projections  of  the  rectum  are 
genuine  valves ;  that  they  are  sufficiently  strong  to  bear  the 
whole  weight  of  the  faecal  mass,  and  to  retard  its  downward 
movement  and  cause  it  to  take  a  winding  direction  ;  and  that 
they  exert  great  opposition  to  the  introduction  of  the  finger, 
the  bougie  or  any  other  instrument  not  in  the  shape  of  a  cork- 
screw. 

The  anatomical  evidence  against  the  existence  of  veritable 
valves  in  the  rectum  is  corroborated  by  numerous  facts,  a  few 
of  which  I  will  now  adduce. 

I  maintain  that  the  irregular  folds  of  the  mucous  membrane 
of  the  rectum,  supposed  to  be  valves  by  the  several  authors  I 
have  named,  are  not  permanent,  but  purely  accidental,  and 
are  caused  by  the  partial  contraction  of  the  intestine.  This 
can  be  verified  by  any  one,  by  carefully  examining  this  mem- 
brane in  the  same  subject  on  different  days,  at  such  time  when 
the  rectum  is  not  distended ;  and  these  folds  will  be  found 
each  time  to  be  more  or  less  changed  in  appearance,  and  to 
occupy  different  situations.  Not  so  with  veritable  valves  any- 
where in  the  body. 


THE    PHYSICAL    EXPLORATION    OF    THE    RECTUM.  17 

I  further  maintain  that  valves,  such  as  described  by  Mr. 
Houston,  capable  of  supporting  the  whole  weight  of  the  fsecal 
matter  collected  in  the  rectum,  and  of  resisting  the  introduc- 
tion of  the  bougie  or  the  finger,  would  most  certainly  be  easily 
distinguishable  and  demonstrable  in  the  living  body ;  and  in  the 
dead  body  the  removal  of  the  organ  ought  not  to  obliterate  them, 
but  on  the  contrary,  that  they  should  be  capable  of  being  demon- 
strated easily,  and  at  any  period  previous  to  decomposition. 

I  deny  most  positively  that  these  plicae,  except  in  an  indu- 
rated or  diseased  state,  are  ever  firm  and  unyielding ;  on  the 
contrary,  they  are  soft,  pliable  and  unresisting,  being  easily 
displaced  by  a  proper  size  bougie,  or,  if  in  reach,  by  the  ex- 
tremity of  the  index  finger,  either  being  well  lubricated,  and 
gradually  introduced  into  the  rectum.  Should  there  be  resist- 
ance, it  will  be  found  not  to  be  occasioned  by  valves,  but 
either  by  faecal  accumulation,  by  the  promontory  of  the  sacrum, 
by  contraction  of  the  rectum,  by  one  or  more  tumors,  by  chronic 
irritation  or  inflammation  of  the  mucous  lining,  by  spasm  in 
nervous  and  irritable  subjects,  &c.  I  have  often  found  that  a 
small  size  rectal  bougie,  say  a  number  two  English,  will  be  apt 
to  become  hooked  or  entangled  in  these  folds  or  superabundant 
membrane,  whilst  one  of  a  much  larger  size  will  so  dispose  of 
them  as  to  pass  readily.  A  small  sound,  as  a  general  rule,  the 
organ  being  in  a  normal  and  healthy  state,  will  often  encounter 
much  more  resistance  than  a  larger  one,  as  any  one  must  have  ex- 
perienced who  has  frequently  sounded  the  rectum  or  the  urethra. 

Veritable  valves  contain  muscular  fibres  and  are  capable  of 
firmly  constricting  the  bowel,  and  can  never  be  entirely  effaced 
by  distension,  I  care  not  how  far  it  is  carried  in  length  and  in 
width  ;  not  so  these  irregular  folds,  for  they  may  be  completely 
defaced  by  this  process.  In  my  anatomical  investigations,  I 
have  found  in  the  small  intestines,  independent  of  the  valvulse 
conniventes,  precisely  such  a  valve-like  arrangement  of  the 
mucous  tunic,  which  may  also  be  entirely  effaced  by  disten- 
sion. Others  have  discovered  and  reported  the  same. 

A  very  important  office  of  the  valvulse  conniventes  is  doubt- 
less to  prevent  the  alimental  mass  from  passing  along  the  intestine 
too  rapidly,  before  its  nutritive  particles  are  taken  up  by  the  ab- 
sorbents, which  it  would'otherwise  readily  do,  being  quite  fluid. 
The  greater  development  of  these  valvulse  in  the  superior  por- 


18  THE   PHYSICAL    EXPLORATION    OF   THE   RECTUM. 

tion  of  the  small  intestines  is  a  curious  phenomenon,  since  the 
fluid  contained  in  this  portion  possesses  the  most  nutritious 
properties.  Yalves,  besides  delaying  the  substances  in  the 
intestinal  canal,  also  prevent  the  regurgitation  or  reflux  of  its 
contents,  provided  they  are  fluid  or  gaseous.  The  reflux  of 
consistent  faecal  matter,  however,  is  impossible.  From  these 
considerations  a  very  strong  inference  may  be  drawn  that  there 
is  no  necessity  for  valves  in  the  rectum,  inasmuch  as  the  faecal 
mass,  before  reaching  this  point,  has  been  entirely  deprived  of 
its  nutritious  as  well  as  fluid  properties,  and  merely  being  ar- 
rested here  and  detained,  not  by  valves  but  by  the  sphinctores 
ani  muscles,  to  await  its  final  expulsion. 

Veritable  valves  sufficiently  large  and  strong  to  obstruct  or 
dam  up  the  inferior  extremity  of  the  rectum,  is  simply  ridicu- 
lous ;  such  never  have,  and  in  my  opinion  never  can  be  demon- 
strated, the  able  authorities  I  have  quoted  to  the  contrary  not- 
withstanding. I  admit  that  these  accidental  folds  of  the  rectum 
resemble  the  valvulse  conniventes  of  the  small  intestines,  that 
they  look  like  valves ;  yet  they  lack  the  essential  attributes, 
and  consequently  are  not  valves. 

The  foundation  of  Mr.  Houston's  error  in  relation  to  these 
folds  of  the  mucous  membrane  of  the  rectum,  was  his  peculiar 
method  of  investigation.  He  did  not  examine  this  membrane 
in  its  natural  state ;  indeed,  his  procedure  was  anything  but 
natural,  although  he  intimates  that  it  is  the  only  method  by 
which  the  condition  of  these  valves,  as  he  calls  them,  can  be 
displayed.  Now  it  is  well  known  to  anatomists  that  such  a 
mode  of  proceeding  is  entirely  unnecessary  to  the  exhibition 
of  the  valvulae  conniventes,  or  of  any  valves  in  the  body ;  that 
such  valves  were  never  discovered  and  demonstrated  by  such 
a  process.  The  following  remarks  of  Dr.  Bushe  upon  this 
point  are  so  just,  that  I  will  quote  them.  "  With  all  due  defer- 
ence to  Mr.  Houston,  I  would  beg  to  remark  that  his  misap- 
prehension of  this  piece  of  anatomy  has  arisen  from  his 
methods  of  investigation :  one  by  filling  the  intestine  with 
alcohol,  and  then  opening  it ;  the  other  by  inflation  and  drying. 
In  the  first  the  accidental  folds  are  rendered  permanent  by  the 
induration  resulting  from  the  action  of  the  alcohol ;  while  in 
the  second,  the  projections  resembling  valves  are  produced  by 
the  angles  formed  by  the  setting  of  the  intestine  during  the 
process  of  dessication."  (Op.  Git.  p.  13.) 


SECTION  III. 

PHYSICAL      EXPLORATION. 

1.  In  the  diseases  of  the  rectum  and  anus,  the  diagnosis  is 
principally  determined  by  a  visual  and  a  tactile  examination 
of  the  parts.     The  proper  instruments  to  be  employed  for  this 
purpose  are  the  index-finger  of  the  right  hand,  the  8peculv/m 
ani,  the  rectal  endoscope,  the  rectal  exploring  sound,  the  rectal 
bougie,  a  gas  or  oil  lamp  with  a  reflector  and  a  lens  attached, 
a  suitable  silver  probe  for  the  exploration  of  fistulas,  fissure, 
&c.,  and  an  acupuncture  or  exploring  needle,  or  a  small  trocar, 
to  test  the  character  of  ambiguous  swellings  or  fluid  collections, 
when  met  with  in  these  parts.    By  this  last-named  instrument 
we  are  enabled  at  once  to  determine  whether  fluid  exists  or 
not  in  such,  and,  if  it  does,  whether  it  is  pus,  serum,  or  blood. 

2.  Digital   and  Specular   Examination. — In    the   inferior 
portion  of  the  rectum  the  principal  information  may  be  ob- 
tained by  the  digital  examination  alone.     By  means  of  the 
practiced  finger,  moved  about  in  different   directions  within 
the  canal,  tumors,  foreign  bodies  and  ulcers  may  readily  be 
detected  when  within  reach,  and  their  locality,  size  and  char- 
acter accurately  determined  ;  by  it,  too,  contractions  of  the 
passage  may  also  be  discovered,  when  low  down.    Indeed,  the 
examination  with  the  finger  will  generally  enable  the  surgeon 
to  satisfy  himself  most  fully  as  to  figure,  texture  and  tendency. 
It  cannot  be  expected,  however,  that  practitioners  in  general, 
who  necessarily  have  not  the  opportunities  of  acquiring  the 
tactus  erudinis,  should  be  expert  in  determining  by  the  finger 
alone  the  true  condition  of  the  case.     This  knowledge  can 
only  be  acquired  by  time  and  extensive  practice  and  experi- 
ence. 

The  hand  is  sometimes  used  to  explore  the  rectum,  and  aus- 
cultation and  percussion  may  also  be  advantageously  employed 
as  diagnostic  measures  in  diseases  of  this  organ. 


20  THE   PHYSICAL    EXPLORATION    OF    THE    RECTUM. 

3.  Preliminary  Steps. — Preparatory  to  making  a  thorough 
inspection  of  the  rectum,  and  a  few  hours  previous,  this  intes- 
tine should  be  completely  emptied  by  either  a  dose  of  castor 
oil,  or  a  relaxing  enema,  or  by  means  of  both.     The  patient 
should  be  requested  to  empty  the  bladder  also.     Should  there 
exist,  as  is  sometimes  the  case,  exquisite  sensibility  of  the  anus 
and  anal  region,  especially  when  attended  by  pain  and  spasm 
of  the  anal  sphincters,    the  patient   for  examination   should 
always,  if  nothing  contra-indicates  it,  be  put  under  the  influ- 
ence of  sether  or  chloroform  ;  for  without  its  use,  it  -would  be 
impossible,  in  such  a  state  of  the  parts,  to  make  any  satisfactory 
exploration.     By  its  influence,  the  spasm  of  the  excitable  mus- 
cles yields,  and  a  thorough  examination  may  be  made,  which 
otherwise  could  not  be  without  subjecting  the  patient  to  intense 
suffering  and  distress.   In  such  cases,  instead  of  the  ansesthetic, 
I  sometimes  administer   the  following   suppository   an  hour 
before  the  examination,  which  usually  has  a  most  soothing, 
relaxing  and  happy  effect : — 

Recipe,  Extract!  Belladonnas,  granum  unam, 
Morphias  Sulphatis,  granum  dimidiam, 
Butyri  Cacao,  scrupulum. 

Misce  et  fiat  suppositorium. 

4.  Position  of  the  Patient. — The  rectum  and  the  bladder 
being  both  completely  emptied,  the  patient  should  be  placed 
upon  his  left  side,  on  the  edge  of  a  bed  or  table,  at  least  two 
feet  and  a  half  high,  in  front  of  a  strong  light ;  the  back  and 
hips  as  near  the  edge  as  possible ;  the  pelvis  elevated,  the 
head  and  shoulders  depressed,  and  the  thighs  flexed  upon  the 
abdomen ;  and  in  this  position  he  should  be  anaesthetized,  if 
deemed  necessary.     Should  the  peculiar  nature  of  the  case, 
however,  require  it,  the  patient  may  be  placed  precisely  in  the 
position  for  lithotomy  ;  or,  if  a  male,  he  might  lean  over  the 
back  of  a  suitable  chair,  with  his  hands  resting  on  the  front 
edge  of  it,  his  head  being  depressed  and  nates  elevated ;  or 
place  himself  across  a  bed  on  his  hands  and  knees,  with  his 
head  depressed.     Whatever  position  is  selected,  a  strong  light 
is  indispensable  to  success,  especially  when  the  speculum  is  to 
be  used. 

The  surgeon  being  placed  in  an  easy  and  convenient  posi- 


THE    PHYSICAL    EXPLORATION    OF    THE    RECTUM.  21 

tion,  with  his  right  arm  next  to  the  patient,  who  occupies  the 
first  position  named,  should  proceed  to  make  the  examination, 
either  with  the  right  index-finger,  the  hand,  the  speculum,  the 
endoscope,  the  sound,  the  bougie,  the  probe,  or  any  other  in- 
strument, or  of  each  one  of  these  in  turn,  if  requisite. 

5.  The  Index-Finger. — The  index-finger  of  the  right  hand, 
after  paring  the  nail  smoothly,  and  being  warmed  and  well 
lubricated  with  either  cacao  butter,  cold  cream,  the  white  of  an 
egg,  olive  oil,  or  castile  soap,  should  be  gently  and  gradually 
insinuated  into  the  anus  and  anal  canal.     Any  attempt  to 
penetrate  roughly  or  rapidly  will  be  very  liable   to  excite 
resistance  from  the  anal  muscles,  and  the  passage  of  the  finger 
or  other  instrument  in  such  manner  would  occasion  more  or 
less  suffering  or  after  distress,  and  greatly  interfere  with  the 
progress  of  the  examination.     In  the  use  of  the  finger,  it  is 
well  to  know,  that  by  introducing  it  from  behind,  the  surgeon  is 
enabled  to  push  it  much  further  into  the  canal  than  if  he  intro- 
duced it  from  before  or  laterally  ;  and  it  is  also  worth  know- 
ing, that  a  tumor  or  a  stricture  of  the  rectum,  when  beyond  the 
reach  of  the  finger,  may  sometimes  be  pressed  down  within 
reach  of  it,  by  the  patient  making  defecating  efforts. 

6.  Palpation. — In  order  to  arrive  at  a  positive  diagnosis  in 
certain  morbid  conditions  of  the  rectum  or  other  pelvic  viscera, 
whether  in  reference  to  congenital  malformations  or  to  morbid 
growths,  &c.,  the  right  hand  should  be  used.     This  method  of 
exploring  the  rectum  is  of  great  importance  in  some  instances, 
and  will  avail  much  in  determining  with  certainty  the  real 
state   of  this   or  the   contiguous   organs.     The   hand,   being 
warmed  and  well  lubricated,  should  be  gradually  and  carefully 
introduced  into  the  anus  and  anal  canal,  with  the  backs  of  the 
fingers  and   the  knuckles  presenting   to   the   hollow  of  the 
sacrum,  up  which  it  will  glide,  as  soon  as  the  knuckles  have 
passed  the  sphinctores  ani,  by  dilating  them,  and  entered  the 
rectal  pouch.     It  is  remarkable  how  dilatable  the  anus  and 
the  anal  canal  are. 

7.  Speculum  Ani. — It  is  essentially  necessary,  however,  in 
many  instances,  especially  in  some  morbid  conditions  of  the 


22  THE    PHYSICAL    EXPLORATION    OF    THE    RECTUM. 

mucous  lining  of  the  rectum  inappreciable  by  the  touch,  to 
add  to  these  excellent  means  of  exploration  the  use  of  the  specu- 
lum ani  or  rectal  endoscope,  which  enables  the  surgeon  to 
judge  of  the  disease  by  ocular  inspection.  By  the  aid  of 
these  instruments  he  is  enabled  to  appreciate  the  exact  size, 
shape,  color  and  appearance  of  the  lesion  in  the  affected  parts 
— thus  being  in  full  possession  of  the  facts  as  to  the  actual  ex- 
istence, situation  and  general  appearance  of  such  lesion.  The 
speculum  ani  is  not  only  made  available  for  diagnostic,  but  for 
therapeutic  purposes  also.  It  may  be  used  to  great  advantage 
in  some  of  the  operations  on  this  organ,  as  well  as  in  making 
caustic  applications  to  diseased  portions  of  its  mucous  lining,  etc. 

The  anal  speculum  or  endoscope  is  contra-indicated  in  acute 
inflammation  of  the  anus  or  the  rectum,  or  when,  by  the  touch, 
the  existence  of  extensive  carcinomatus  degeneration  of  the 
rectum  has  been  ascertained.  In  epithelioma,  if  the  symptoms, 
— such  as  continued  severe  pain  and  a  constant  discharge  of  a 
sanio-purulent  matter — show  that  extensive  ulceration  has 
attacked  the  parts,  it  is  useless  and  even  hurtful  to  introduce 
the  speculum,  bougie  or  sound,  and  indeed,  in  such  a  case,  the 
less  interference,  even  with  the  finger,  the  better. 

The  speculum  which  I  most  commonly  use  is  the  bi-valve 
instrument  (represented  by  Fig.  5).  It  may  be  made  of  polished 

FIG.  5. 


steel  or  silver-plated.  The  only  objection  that  can  be  urged 
against  this  instrument  is,  that  in  instances  in  which  there  is  a 
superabundance  of  mucous  membrane  and  integument  at  the 
anal  extremity  of  the  rectum,  it  too  readily  permits  their  pro- 
trusion between  its  blades,  and  thus  more  or  less  prevents  an 
accurate  inspection  of  the  parts.  No  straight  speculum  ani 
should  exceed  four  or  four-and-a-half  inches  in  length. 


THE   PHYSICAL    EXPLORATION    OF    THE    RECTUM.  2o 

I  usually  make  the  digital  examination  first,  before  using  the 
speculum  ;  the  finger  dilates  the  anus  and  anal  canal  and  pre- 
pares the  parts  for  the  easy  entrance  of  this  instrument.  The 
speculum,  like  the  finger,  should  be  warmed  and  well  lubricated 
before  being  introduced  ;  it  should  then  be  inserted  into  the 
anus,  and  gently  and  slowly  directed  a  little  forward  and  upward 
for  about  one  inch  and  a  half,  as  if  to  pass  from  the  perinseum 
to  the  umbilicus,  in  order  that  it  may  follow  the  course  of  the 
anal  canal ;  having  reached  this  depth,  which  is  a  little  greater 
in  the  male  than  in  the  female,  the  point  should  then  be  in- 
clined backward,  first  slightly,  and  afterwards  to  a  greater 
extent,  and  thus  follow  the  curve  of  the  sacrum,  until  the  in- 
strument is  fully  in  ;  it  should  then  be  opened  and  rotated 
until  the  whole  mucous  surface  of  the  lower  end  of  the  bowel 
is  clearly  brought  into  sight.  Should  the  view  be  obstructed 
in  the  least,  by  either  mucus,  blood  or  faeces,  a  small  mop, 
made  of  fine  sponge,  and  attached  to  the  end  of  a  rod,  should 
be  at  hand  to  remove  any  of  these  matters.  The  speculum 
should  then  be  carefully  withdrawn  with  its  blades  partially 
open. 

I  have  found  the  tri-valve  trellis  speculum  ani  (represented 
by  Fig.  6,)  a  very  valuable  instrument  for  the  purpose  of  discov- 


ering fissures  and  other  ulcers  of  the  rectum.  I  devised  it  a 
number  of  years  ago,  as  an  instrument  to  be  used  in  detecting 
the  bleeding  vessel  in  case  of  traumatic  haemorrhage  of  the 
rectum.  It  is  small  when  closed,  and  easy  of  introduction, 
and  when  introduced  admits  of  extensive  expansion  by  simply 
revolving  the  handle. 


24  THE    PHYSICAL    EXPLORATION    OF    THE    RECTUM. 

As  an  anal  speculum,  especially  in  cases  of  fissure  of  the 
anus,  I  have  also  found  the  simple  and  highly  polished  steel 
instrument,  in  the  form  of  a  large  blunt  gorget  (as  delineated 
by  Fig  7),  very  efficient  and  valuable.  It  is  passed  up  into 


FIG.  7. 


the  rectum  on  the  finger  with  its  concavity  looking  towards 
the  seat  of  the  disease,  and  when  in  to  the  depth  of  two  and  a 
half  or  three  inches,  the  mucous  surface  of  the  canal  at  that 
height  can  be  plainly  seen  reflected  on  its  polished  concave 
surface  ;  at  the  same  time  the  lower  portion  of  the  canal  can 
be  most  accurately  examined  by  the  eye  alone,  by  causing  the 
patient  to  evert  the  anus  as  much  as  possible.  By  passing 
this  instrument  gently  and  slowly  around  the  canal,  the  whole 
internal  surface  of  it  may  thus  be  accurately  inspected.  It 
requires  a  strong  and  bright  light.  The  idea  of  using  an  in- 
strument of  such  a  form  was  first  suggested  by  the  late  and  em- 
inent Mr.  Colles  of  Ireland,  who  objected  to  the  various  kinds 
of  anal  speculae  in  common  use,  and  employed  for  this  purpose 
the  large  blunt  gorget,  and  found  it  superior  to  any  other. 
He  subsequently  made  an  improvement  on  it.  In  order  to 
introduce  it  with  greater  facility,  he  accurately  fitted  it  to  one 
side  of  a  conical  piece  of  polished  box -wood  representing  in  its 
transverse  section  a  full  ellipse,  so  that  when  both  were  joined 
they  presented  a  perfectly  smooth  outline.  After  the  instru- 
ment thus  united  was  introduced  to  the  proper  depth,  the 
wooden  plug  was  withdrawn.  (Dublin  Hospital  Reports, 
Vol.  V.,  p.  155.  Dublin,  1830.) 

The  instrument  I  designed  is  easy  of  introduction  upon  the 
finger  without  the  use  of  the  plug.  A  somewhat  similar  in- 
strument was  designed  by  Mr.  Mudge  of  England,  in  1789,  for 


THE   PHYSICAL    EXPLORATION   OF   THE    RECTUM.  25 

facilitating  the  operation  for  anal  fistula.  (Memoirs  of  the 
Medical  Society  of  London,  Vol.  IV-,  p.  16.  London, 
1795.) 

On  a  dark  day  or  whenever  a  strong  light  is  required 
in  making  rectal  examinations,  I  always  use  the  portable  ap- 
paratus (depicted  in  Fig.  8).  It  consists  of  a  lamp  with  a 


FIG.  8. 


G.TLEMAHN  &  CO. 


reflector  and  a  lens  attached.  It  can  be  used  for  gas,  oil  or 
any  other  illuminating  material.  This  apparatus  is  indispens- 
able when  the  endoscope  is  used. 

.8.  Recto-Colonic  Endoscope.  I  have  thus  denominated  the 
instrument  by  the  use  of  which  and  a  powerful  light,  the 
superior  portion  of  the  rectum  and  inferior  part  of  the  sigmoid 
flexure  of  the  colon  may  be  accurately  and  minutely  examined. 
It  renders  accessible  to  inspection  a  portion  of  the  intestinal 
canal,  a  part  of  the  iliac  colon,  which  has  heretofore  been 
shrouded  with  impenetrable  darkness,  and  which  is  so  often 


26  THE   PHYSICAL    EXPLORATION    OF    THE    RECTUM. 

the  seat  of  disease.     This  instrument  (represented  by  Fig.  9) 

FIG.  9. 


G.TIEMANW-CO.NY. 


[1.  The  endoscope  ready  to  be  introduced,  with  the  conductor  in  situ.  2.  The 
endoecope  in  the  colon,  with  the  internal  mirror  in  situ.  3.  The  internal  reflecting 
mirror.] 

is  the  result  of  the  conjoint  labors  of  the  author  and  the  in- 
genious Mr.  Stohlmann,  of  the  firm  of  Messrs.  George  Tiemann 
&  Co.,  surgical  instrument  makers,  New  York.  It  consists  of 
a  hollow  cylinder,  fourteen  inches  long  and  seven-eighths  of  an 
inch  in  diameter,  made  of  steel  or  German  silver,  the  interior 
of  which  being  highly  polished.  Four  inches  of  the  proximal 
end  is  solid,  the  remainder  is  flexible,  so  as  to  be  capable  of 
adapting  itself  to  the  curve  of  the  rectum  and  that  at  the  junc- 
tion of  the  rectum  and  colon.  To  facilitate  the  introduction 
of  the  instrument,  it  is  supplied  with  a  conductor,  consisting 
of  a  slender  whalebone  rod  about  two  inches  longer  than  the 
cylinder  itself,  to  the  end  of  which  is  fastened  a  conical  piece 
of  ivory,  ebony  or  hard  rubber,  an  inch  and  a  half  long,  and 
of  such  diameter  as  to  pass  into  and  out  of  the  cylinder -with 
ease,  and  to  project  at  least  an  inch  beyond  the  distal  end  of  it. 
With  the  conductor  thus  in  situ,  the  instrument  is  warmed,  lu- 
bricated and  introduced  to  the  desired  height,  and  the  conduc- 
tor then  withdrawn.  The  instrument  is  also  furnished  with 
an  internal  reflecting  mirror,  fixed  on  the  end  of  a  wire  rod  at 
least  thirteen  inches  long.  The  mirror  being  attached  to  the 
rod  by  a  movable  joint,  enables  it  to  be  easily  adjusted  to  any 
desirable  angle.  The  internal  mirror  is  only  used  when  the 
inferior  part  of  the  sigmoid  flexure  of  the  colon  is  to  be  ex- 
amined. It  must  be  introduced  into  the  cylinder  as  far  as  the 
angle  formed  by  the  junction  of  the  rectum  and  colon,  at  which 


THE    PHYSICAL    EXPLORATION    OF   THE   KECTUM.  27 

point,  if  properly  placed  and  adjusted,  the  mucous  surface  of 
the  inferior  portion  of  the  iliac  colon  for  some  distance  beyond 
may  be  plainly  seen  reflected  in  it,  when  the  focus  of  light 
from  the  external  reflector  is  thrown  upon  it. 

As  this  instrument  was  gotten  up  with  considerable  haste,  it 
may,  upon  further  trial,  be  found  to  need  some  improvements. 

9.  Rectal  Eversion  as  a  Means  of  Diagnosis.  Professor 
Horatio  R.  Storer,  surgeon  to  the  Franciscan  Hospital  for 
women,  at  Boston,  repudiates  the  anal  speculum  as  a  means  of 
diagnosis  in  the  rectal  diseases  of  females,  and  substitutes  for  it 
rectal  eversion.  The  modus  operandi  of  this  proceeding,  ac- 
cording to  him,  is  as  follows  : — "  By  passing  the  finger  into 
the  vagina,  and  pressing  it  backward  and  downward  over  the 
levator  ani,  the  rectum  can  be  everted  through  its  sphincter, 
like  the  finger  of  a  glove.  This  can  ordinarily  be  done  to 
a  very  great  degree,  it  can  always  be  done  to  a  certain 
extent.  Should  the  sphincter  be  unusually  irritable,  and 
spasmodically  contracting  with  violence  when  touched  from 
below,  or  thus  from  above,  it  can  be  forcibly  distended 
by  the  thumbs,  and  temporarily  ruptured,  as  I  am  in  the  habit  of 
doing  in  such  cases ;  the  procedure  above  indicated  thus  be- 
coming easy.  We  can  in  this  manner  ascertain  the  presence 
of  a  chancre  or  chancroid,  the  character  of  polypi,  the  extent 
and  number  of  internal  haemorrhoids,  the  position  of  the  inner 
orifice  in  fistula,  &c.,  with  far  greater  certainty  and  alacrity 
than  by  the  speculum,  or  can  be  done  in  the  male,  while  the 
mere  eversion  process,  provided  rupture  of  the  sphincter  is  not 
necessary,  is  attended  by  very  little  pain."  (American  Jour- 
nal of  Obstetrics.  Vol.  I., p.  71.  New  York,  1869.) 

This  expedient  of  Dr.  Storer  can  only  be  made  available  to 
the  extent  of  the  rectal  eversion  and  no  further.  If  the  rectum, 
therefore,  cannot  be  everted  to  its  full  length,  the  speculum  and 
endoscope  cannot  be  altogether  dispensed  with.  He  says  the 
rectum  can  be  ordinarily  everted  through  the  sphincter  like 
the  finger  of  a  glove.  Now,  if  he  means  what  his  language 
implies,  that  the  entire  organ  with  its  several  coats  can  be  so 
everted,  I  do  not  agree  with  him.  I  cannot  conceive  how  this 
can  ordinarily  take  place  to  any  considerable  extent,  or  to 
such  an  extent  as  to  dispense  altogether  with  the  rectal  specu- 
lum. I  maintain  that  eversion  of  the  rectum,  under  the  most 
3 


28  THE   PHYSICAL    EXPLORATION   OF   THE    RECTUM. 

favorable  circumstances,  is  only  partially  practicable.  The 
firm  union  of  this  intestine  with  the  surrounding  parts,  the 
longitudinal  direction  of  its  strongest  and  most  numerous 
fibres,  together  with  the  action  of  the  levatores  ani  muscles, 
offer  too  great  a  resistance  ordinarily  to  the  descent  of  but  a 
very  limited  portion  of  the  rectum.  A  small  portion  of  the 
organ  being  acted  upon  by  firm  and  severe  pressure  from  with- 
in the  vagina,  may  be  made  to  descend  in  an  inverted  state 
through  that  part  of  the  canal  embraced  by  the  anal  sphincters, 
leaving  this  lower  or  embraced  portion,  however,  about  one 
inch  and  a  half  unmoved  from  its  situation,  and  unaltered  in 
its  connections  with  the  surrounding  parts.  If  Dr.  Storer, 
however,  means  by  rectal  eversion,  eversion  of  the  mucous 
lining  only  of  the  rectum,  then  his  procedure  is  a  little  more 
plausible  and  will  be  found  a  little  more  practicable.  This 
membrane,  for  some  distance  above  the  anus,  adheres  but 
slightly  to  the  muscular  coat,  their  connection  being  effected 
by  means  of  a  very  lax  cellular  tissue.  The  mucous  tunic  of 
the  rectum,  then,  in  consequence  of  its  great  amplitude  and 
elasticity,  and  its  very  loose  connection,  may,  indeed,  be  more 
readily  everted,  and  to  a  greater  extent  than  the  rectum  itself. 
But  neither  the  eversion  of  the  rectum  nor  its  mucous  mem- 
brane can  ever  take  place  to  the  extent  of  superseding  the  use 
of  the  anal  speculum  as  an  indispensable  means  of  diagnosis  in 
the  rectal  diseases  of  females. 

In  connection  with  rectal  eversion,  Dr.  Storer  recommends 
the  rupture  of  the  anal  sphincter  as  a  diagnostic  measure,  and 
speaks  of  it  as  flippantly  as  if  the  operation  and  its  conse- 
quences were  as  trifling  in  their  nature  as  the  mere  breaking 
of  a  lady's  garter  or  apron  string.  From  the  great  capacity  of 
the  anus  and  anal  canal  naturally  for  dilatation,  I  positively 
assert  that  they  can  always  be  most  readily,  speedily  and 
safely  dilated  under  the  influence  of  anaesthetics  or  belladonna, 
without  carrying  the  dilatation  to  the  extent  of  rupturing  the 
anal  sphincter,  or  causing  any  injury  whatever  to  the  integrity 
of  the  parts.  This  breaking  of  the  anal  sphincter  then,  merely 
as  a  diagnostic  measure,  as  advised  by  Dr.  Storer,  is,  in  my 
opinion,  not  at  all  justifiable  under  the  circumstances.  It  is 
bad  enough,  in  all  reason,  when  practiced  as  a  therapeutic 
measure. 


THE    PHYSICAL    EXPLORATION    OF    THE    KECTUM.  29 

10.  Splanchnoscopy  by  Translucency . — This  method  of  ex- 
ploration is  attracting  great  attention  at  present,  and,  if  ever 
perfected,  might  be  made  available  in  the  examination  of  the 
rectum.  The  method  of  illumination  by  translucency,  as 
advocated  by  M.  Milliot,  who  demonstrated  it  to  the  late  Inter- 
national Congress  in  Paris,  at  one  of  its  evening  sessions,  con- 
sists in  introducing  into  the  stomach  or  rectum,  glass  tubes,  of 
small  caliber,  containing  two  platinum  wires,  connected  with 
the  electrodes  of  the  galvanic  apparatus  of  Middeldorpff  of 
Breslau.  It  is  in  this  manner  that  an  intense  illumination 
may  be  transmitted  into  the  visceral  cavities,  rendering  them 
translucent.  At  any  rate,  this  artificial  illumination,  even  if 
it  does  not  result  in  rendering  the  walls  transparent  or  rather 
translucent,  might  be  made  available  in  exploring  or  in  operat- 
ing upon  the  rectal,  vaginal,  buccal  and  nasal  passages. 

I  have  seen  it  stated,  in  a  late  number  of  the  London  Lan- 
cet, that  Dr.  Richardson  exhibited,  at  the  British  Society  for 
the  Advancement  of  Science,  a  lamp  which  he  had  constructed 
for  transmitting  light  through  the  structures  of  the  animal 
body.  He  believed  that  the  idea  that  this  could  be  effected 
was  given  in  Priestley's  Work  on  Electricity ;  that  great 
chemist  had  observed,  on  passing  a  discharge  of  a  Leyden  bat- 
tery through  his  finger,  that  the  structure  seemed  to  present 
luminosity  ;  but  the  operation  was  painful.  A  suggestion  of 
Dr.  Mackintosh,  last  year  at  Dundee,  had  been  acted  on  by 
Dr.  Richardson,  who  had  observed  the  motion  of  the  heart 
and  of  respiration  by  direct  ocular  demonstration,  while  these 
organs  were  under  the  influence  of  various  bodies  belonging 
to  the  ethyl  and  methyl  series.  Dr.  Richardson  had  so  far 
extended  the  principle,  that  he  was  enabled  to  transmit  light 
through  various  tissues  of  the  bodies  of  large  animals.  The 
particular  details  of  all  these  interesting  and  elaborate  experi- 
ments he  described.  In  a  child,  the  bones  could  be  seen  in 
the  arm  and  wrist.  The  movements  and  outline  of  the  heart 
could  also  be  seen  in  the  chest. 

The  numerous  experiments  now  being  made  on  the  subject 
of  the  transmission  of  light  through  the  tissues  of  the  body, 
rendering  them  translucent,  may  ere  long  lead  to  the  most 
startling  and  wonderful  discoveries. 


30  THE   PHYSICAL    EXPLORATION   OF   THE    RECTUM. 

11.  Exploration  with  the  Probe. — In  making  anal  and  rec- 
tal examinations,  I  sometimes  use  the  silver  probe  alone  (Fig. 


FIG.  10. 


G.U&MANN-CQ. 


10).  It  is  seven  or  eight  inches  long,  and  is  valuable  for  de- 
tecting blind  external,  internal  and  complete  anal  fistulae, 
anal  fissure,  f*5  well  as  sacculi  of  the  anus.  The  use  of  it  obvi- 
ates the  necessity,  generally,  of  distending  the  anus  with  the 
fingerorthe  speculum,  hence  the  extreme  suffering  consequent 
upon  such  distention,  especially  in  anal  fissure,  is  entirely 
avoided.  No  anaesthetic  generally  need  be  employed.  In 
searching  for  anal  fissure  I  use  the  probe  slightly  curved  at  its 
distal  end  (Fig.  11).  It  should  be  dipped  in  olive  oil  or  gly- 

FIG.  11. 


cerine,  and  gently  introduced  several  inches  up  the  canal ; 
then  it  should  be  brought  down  gradually,  with  its  curved 
point  pressing  upon  the  side  or  wall  of  the  canal,  and  as  soon 
as  it  comes  in  contact  with  the  fissure,  the  patient  will  at  once 
manifest  it  by  the  sensation  of  pain  he  will  experience.  This 
exploration  with  the  probe  may  be  continued  around  the  whole 
circuit  of  the  canal,  until  the  fissure  or  ulcer  is  detected.  In 
searching  for  occult  or  blind  internal  fistulas  and  preternatural 
pouches  of  the  anus,  I  also  use  a  hooked  probe,  for  they  are 
most  easily  detected  by  such  an  instrument.  About  half  or 
three-fourths  of  an  inch  of  the  distal  end  of  the  silver  probe 
should  be  bent  back  upon  itself  so  as  to  form  a  kind  of  hook 
(Fig.  12),  somewhat  like  that  already  recommended  for  search- 

FIG.  12. 


THE   PHYSICAL    EXPLORATION   OF   THE   KECTUM.  31 

ing  for  anal  fissure.  The  probe  thus  bent  should  be  passed  up 
the  canal  three  or  four  inches,  and  brought  slowly  back  with 
the  point  bearing  successively  on  the  different  parts  of  the  cir- 
cumference of  the  rectum.  Should  an  occult  fistula  or  a  sac 
exist,  the  reverted  point  of  the  probe  will  pass  into  its  orifice 
and  cavity,  and  render  its  existence  and  character  'at  once 
sufficiently  obvious. 


SECTION  IY. 

SOUNDING   THE    RECTUM. 

1.  Sounding  the  rectum  and  sigmoid  flexure  of  the  colon, 
as  the  operation  may  be  termed,  is  sometimes  attended  with 
considerable  difficulty.  It  is  an  operation  which  requires 
practice,  accurate  anatomical  knowledge,  and  a  certain  number 
of  precautions. 

The  operator  must  bear  in  mind  that  the  rectum  in  its 
course  through  the  pelvis  lies  in  close  relation  with  the  pros- 
tate gland,  vesiculce  seminales,  bladder  and  urethra,  in  the 
male,  and  with  the  uterus  and  the  vagina  in  the  female ;  and 
he  must  also  bear  in  mind  the  very  important  fact  that  this 
intestine  pursues  a  course  by  no  means  straight,  as  its  name 
imports,  but  that  it  is  more  or  less  curved,  both  in  its  antero- 
posterior  and  lateral  direction,  hence  in  the  introduction  of  the 
finger,  the  pipe  of  the  enema  syringe,  the  bougie,  the  sound, 
&c.,  it  should  be  directed  at  first  upward  and  forward,  and 
then  upward  and  backward.  In  the  child,  however,  this  pre- 
caution is  not  so  necessary,  for  in  it  the  course  of  this  intestine 
is  not  so  much  curved,  the  name  rectum  being  then  more  ap- 
propriately applied  than  in  the  adult.  The  introduction  of  in- 
struments into  the  rectum,  therefore,  requires  not  only  a 
knowledge  of  the  curve  which  this  intestine  takes,  but  of  the 
axis  of  the  pelvis  also.  Particular  attention  should  be  paid  to 
the  disposition  or  direction  of  the  rectum,  as  an  anatomical  fact, 
from  which  important  practical  inductions  of  the  greatest  in- 
terest may  be  derived,  especially  as  leading  to  a  much  greater 
accuracy  of  diagnosis  on  the  part  of  the  surgeon. 

The  surgeon,  too,  must  not  forget  that  the  mucous  lining  of 
the  rectum  is  quite  delicate  and  highly  sensitive,  and  very 
liable  to  be  injured  by  any  rough  manipulation.  In  consider- 
ation, therefore,  of  these  several  facts,  all  instruments  that  are 
to  be  passed  along  this  canal  should  possess  the  commcn  prop- 
erties of  smoothness  and  flexibility,  and  they  should  have  a 


THE   PHYSICAL    EXPLORATION   OF   THE   EECTUM.  33 

certain  degree  of  curvature  imparted  to  them  prior  to  their  in- 
troduction, if  intended  to  go  up  the  canal  more  than  three  or 
four  inches. 

The  rectal  sound,  or  rectal  bougie,  is  the  proper  instrument 
to  be  employed  to  detect  contractions,  tumors,  foreign  bodies, 
or  impacted  faeces  in  the  passage,  when  beyond  the  reach  of 
the  finger. 

2.  Rectal  Exploring  Sound.  The  instrument  which  I  have 
long  used  for  sounding  the  rectum,  and  which  I  prefer  to  any 
other  for  this  purpose,  is  represented  by  Fig.  13.  It  is  com- 

FIG.  13. 


[  1.  The  method  of  introducing  the  sound.     2.  The  rectal  exploring  sound.] 

posed  of  a  conical  piece  of  ivory,  ebony,  or  hard  rubber,  two 
inches  in  length  and  two  and  a  quarter  inches  in  circumference 
at  its  base,  and  well  secured  by  a  screw  to  the  end  of  a  slender 
whalebone  rod,  fourteen  inches  long.  The  whole  instrument  re- 
sembles the  O3sophageal  probang.  The  sound  warmed  and  well 
lubricated  is  introduced  by  inserting  the  left  index-finger  into 
the  anus,  pressing  the  whalebone  rod  a  little  forward,  and  to 
the  left  side,  whilst  with  the  right  hand,  it  is  urged  steadily 
upward.  It  will  be  perceived  that  this  instrument  being 
conical  in  form  does  not,  in  this  respect,  resemble  the  ball 
sound  of  Sir  Charles  Bell,  (Diseases  of  the  Urethra,  Bladder, 
Prostate  and  Rectum.  Third  Edition,  p.  328.  London, 
1822,)  nor  the  oblong  sound  of  Dr.  Bushe.  ( A  Treatise  on  the 


34:  THE   PHYSICAL    EXPLORATION   OF   THE   RECTUM. 

Malformations,  Injuries  and  Diseases  of  the  Rectum  and 
Anus,  p.  284.  New  York,  1837.)  My  instrument,  on  account 
of  its  form,  can  be  introduced  into  the  rectum,  moved  about 
and  withdrawn  with  much  greater  facility,  and  with  much  less 
pain,  if  any,  than  that  of  either  Bell  or  Bushe.  A  sound  or 
bougie  from  half  to  three-quarters  of  an  inch  in  diameter  is 
quite  large  enough  for  sounding  the  rectum.  If  such  a  sized 
instrument  passes  easily  and  without  pain,  it  may  be  presumed 
that  there  is  no  permanent  obstruction  or  disease  of  the 
organ.  I  make  use  of  variable  sizes  of  this  sound  for  dilating 
strictures  of  the  rectum.  It  is  a  most  valuable  instrument  for 
this  purpose. 

3.  The  Rectal  Bougie  as  a  Sound.  The  bougie  is  some- 
times used  for  sounding  the  rectum  and  sigmoid  flexure  of  the 
colon,  and,  in  some  instances,  more  accurate  information  might 
perhaps  be  obtained  by  its  use  than  by  the  use  of  the  sound 
already  named.  In  a  case  of  obstruction  of  the  rectum, 
caused  either  by  a  contraction,  a  tumor  or  foreign  body,  if  a 
soft  and  pliant  bougie,  especially  one  made  of  wax,  is  pressed 
against  the  obstruction,  the  exact  impression  of  it  would  be 
given  by  the  instrument,  and  thus  some  estimate  could  be 
formed  of  the  nature  of  the  difficulty.  In  case  of  stricture,  it 
would  give  the  exact  size  and  form  of  it.  The  bougie,  however, 
is  not  generally  well  borne  by  the  patient  on  account 
of  the  uneasy  or  painful  distention  of  the  anus  it  produces 
in  some  instances  while  exploring.  In  this  respect,  the 
rectal  sound,  it  will  be  observed,  has  decidedly  the  preference, 
inasmuch  as  it  produces  no  distention  of  the  muscles  of  the 
anus  after  having  passed  them  and  during  the  process  of 
sounding.  A  good  bougie  should  always  admit  of  being  ren- 
dered pliant  and  flexible  by  being  immersed  in  hot  water;  yet 
it  should  be  of  sufficient  firmness  to  admit  of  the  gentle  pres- 
sure necessary  to  urge  it  forward  without  too  easily  doubling 
upon  itself  in  case  it  meets  with  some  obstruction.  This 
quality  of  the  bougie  is  very  important,  when  the  anatomy  of 
the  rectum  is  taken  into  consideration,  which  requires  that  the 
instrument  should  be  capable  of  ready  adaptation  to  the 
peculiar  form  and  direction  of  the  passage,  otherwise  its  intro- 
duction would  be  not  only  useless,  but  might  be  productive  of 


THE    PHYSICAL    EXPLORATION    OF    THE    RECTUM.  35 

the  most  serious  mischief:  hence,  no  bougies  made  of  metal, 
bone,  wood,  glass,  or  any  other  hard  or  unyielding  substance, 
should  ever  be  used  for  exploring  the  rectum.  No  straight 
and  inflexible  instrument  can  be  inserted  into  the  rectum 
more  than  four  inches  without  danger  from  its  extremity 
rudely  pressing  against  either  the  angles  of  the  intestine,  the 
promontory  of  the  sacrum,  the  uterus,  the  bladder,  &c.  ;  fur- 
thermore, it  should  ever  be  recollected  that  even  the  best 
sound  or  bougie  for  the  purpose  of  exploring  the  rectum,  is  by 
no  means  a  harmless  instrument  in  rude  and  unpracticed 
hands. 

When  I  use  a  rectal  bougie  for  the  purpose  merely  of  search- 
ing or  sounding  the  rectum,  I  generally  use  one  made  of  white 
wax,  seventeen  inches  long,  and  two  inches  in  circumference, 
and  terminating:  in  a  smooth  round  end.  This  instrument, 

O  ' 

properly  made,  possesses  sufficient  tenacity  to  prevent  its 
breaking  in  the  rectum,  and  when  sufficiently  softened  by  heat, 
so  much  flexibility,  without  elasticity,  that  if  properly  directed  it 
will  readily  accommodate  itself  to  the  curvatures  of  the  passage. 
Before  using,  it  must  always  be  immersed  in  hot  water  until 
it  is  rendered  soft  and  pliable,  and  yet  sufficiently  firm  for  the 
purpose  of  the  exploration.  I  have,  on  several  occasions,  used 
a  number  three  as  well  as  a  number  four  English  rectal  bougie 
for  sounding  the  rectum,  and  have  found  it  a  good  instrument 
for  the  purpose.  The  only  serious  objection  to  its  use  is  that 
it  is  not  long  enough,  when  the  sigmoid  flexure  of  the  colon  is 
to  be  explored.  It  must  also  be  immersed  in  hot  water  be- 
fore using.  The  rectal  tube  of  O'Bernie  is  also  a  valuable  in- 
strument for  this  purpose. 

4.  Method  of  Inserting  the  /Sound,  J3ougie  or  Tube.  The 
operation  of  introducing  the  sound,  bougie  or  tube,  into  the  rec- 
tum, or  into  the  sigmoid  flexure  of  the  colon  with  facility, 
requires,  as  before  remarked,  considerable  dexterity  and 
practice.  In  order  that  students  may  become  adroit  in  their 
manipulations  and  conversant  with  the  anatomy  of  the  rectum, 
they  should  frequently  make  explorations  of  it,  as  well  as 
frequent  dissections  of,  and  operations  upon  it,  in  the  dead 
body. 

The  operation  of  sounding  the  rectum  may  be  divided  into 


36  THE    PHYSICAL    EXPLORATION    OP   THE    RECTUM. 

three  stages  in  accordance  with  the  three  natural  divisions  of 
the  organ  already  described. 

First  Stage.  In  the  first  stage  of  the  operation,  the  instru- 
ment passes  through  the  inferior  third  of  the  rectum.  The 
bougie,  previous  to  insertion,  being  made  pliant  by  immersion 
in  hot  water  and  well  lubricated,  should  have  a  double  curve 
given  it,  if  intended  to  go  beyond  the  rectum  into  the  sigmoid 
flexure  of  the  colon.  The  first  curve  to  correspond  to  the 
hollow  of  the  sacrum,  and  the  second  to  the  lateral  inflection 
of  the  sigmoid  colon  to  the  left. 

The  patient,  after  completely  emptying  the  rectum  and  the 
bladder,  and  being  properly  placed,  an  injection  of  two  or 
three  ounces  of  the  infusion  of  linseed  should  be  thrown  up 
into  the  rectum,  to  be  retained,  in  order  to  facilitate  the  oper- 
ation ;  after  which,  the  point  of  the  bougie  directed  by  the 
operator's  right  index-finger,  should  be  inserted  into  the  anus 
with  the  convexity  of  the  first  curve  of  the  instrument  towards 
the  sacrum,  and  in  this  manner  it  should  be  guided  upward 
and  backward  for  about  two  inches  through  the  inferior  third 
of  the  rectum. 

As  the  last  inflection  of  the  rectum  is  so  very  slight,  it  is  not 
so  important  whether  the  convex  or  concave  part  of  the  bougie 
be  introduced  towards  the  sacrum ;  by  passing  it,  however, 
with  the  concavity  backward,  the  necessity  is  avoided  of 
changing  the  position  of  the  instrument  in  passing  the  main 
curve  of  the  intestine. 

Second  Stage.  In  the  second  stage  of  the  operation,  if  there 
is  no  great  pain  to  centra-indicate  it,  the  operator  should  con- 
tinue to  propel  the  instrument  in  the  same  direction  as  last 
mentioned,  for  about  three  inches  and  a  half  higher,  through 
the  middle  third  of  the  rectum.  The  distal  end  of  the  bougie 
will  now  bear  directly  upon  the  hollow  of  the  sacrum,  whilst 
the  proximal  end  will  bear  toward  the  left  side  of  the  body. 

Third  Stage.  In  the  third  stage  of  the  operation,  in  order 
to  avoid  the  promontory  of  the  sacrum,  and  to  adapt  the  in- 
strument to  the  main  curve  of  the  rectum,  its  position  must  be 
changed,  by  describing  the  segment  of  a  circle  from  left  to 
right,  with  the  proximal  end,  by  turning  it  upward  and  at  the 
same  time  continuing  to  propel  the  bougie  for  about  five  and 
a  half  inches  further.  By  this  manoeuvre  the  instrument  will 


THE   PHYSICAL    EXPLORATION    OF   THE   RECTUM.  37 

have  been  carried  through  the  superior  third  of  the  rectum  to 
the  commencement  of  this  intestine. 

Fourth  Stage. — With  the  design  now  of  introducing  the 
bougie  or  tube  into  the  colon,  which  may  constitute  the  fourth 
stage,  the  proximal  end  of  the  instrument  must  be  slightly 
depressed,  and  at  the  same  time  the  bougie  should  continue  to 
be  propelled  for  five  or  six  inches  further  into  the  sigmoid 
flexure  of  the  colon.  Should  there  be  any  doubt  as  to  the 
bougie  having  passed  into  the  sigmoid  flexure  of  the  colon, 
that  doubt  may  be  removed  by  removing  the  pressure  from 
the  proximal  end  of  the  bougie,  when  if  it  has  not  entered 
the  colon  but  doubled  on  itself,  it  will  slowly  recoil.  An  evi- 
dence, however,  which  almost  invariably  attends  the  passage 
of  the  bougie  or  tube  into  the  sigmoid  colon,  is  the  escape  of 
more  or  less  gas  at  the  moment  of  entrance. 

I  would  here  remark  that  the  sacral  promontory  and  the 
inferior  part  of  the  sigmoid  flexure  of  the  colon,  are  the  two  most 
prominent  points  which  oppose  the  natural  ascent  of  the  instru- 
ment. The  degree  of  resistance,  however,  and  the  peculiar 
sensation  communicated  to  the  hand  by  the  instrument  when 
manipulated  in  the  manner  directed,  will  always  enable  the 
intelligent  and  careful  operator  to  recognize  a  real  obstruction, 
from  the  ordinary  obstacles  which  oppose  its  ascent.  At  the 
termination  of  the  sigmoid  flexure  of  the  colon,  and  the  com- 
mencement of  the  rectum,  so  far  as  my  examinations  have 
gone,  there  will  be  found  in  almost  all  cases  a  slightly  narrow 
neck  or  contraction,  which  seems  to  possess  to  a  certain  extent 
the  properties,  and  performs  somewhat  the  office,  of  a  sphinc- 
ter. It  is  at  this  point  or  spot  that  the  bougie  or  tube  is  mo- 
mentarily arrested,  and  requires  a  little  pressure  and  perse- 
verance to  make  it  pass.  I  would  here  remind  the  operator, 
too,  that  the  colon  is  occasionally  found  to  incline  to  the  right 
instead  of  to  the  left  side ;  should  he  therefore  meet  with  any 
very  ambiguous  resistance  at  the  commencement  of  the  colon, 
the  instrument  should  be  withdrawn  a  little,  and  again  passed 
forward,  with  its  direction  more  or  less  changed,  and  in  this 
manner  endeavor  to  find  the  natural  course  of  the  intestine. 

The  introduction  of  the  bougie  into  the  colon  most  always 
produces  an  uneasy  sensation  over  the  surface  of  the  abdomen, 
more  especially  in  the  umbilical  region,  not  amounting  to 


38  THE    PHYSICAL    EXPLORATION   OF   THE   RECTUM. 

pain,  however,  unless  there  should  be  more  or  less  disease  in 
this  portion  of  the  colon. 

In  introducing  the  bougie  into  the  sigmoid  flexure  of  the 
colon,  I  sometimes  place  the  patient  on  his  back,  across  the 
bed  or  table,  with  his  hips  as  near  as  possible  to  the  edge,  the 
thighs  abducted  and  semi-flexed  upon  the  abdomen,  and  the 
shoulders  elevated.  The  bougie  is  then  introduced  into  the 
anus,  as  before  directed,  and  passed  upward,  with  the  point 
directed  backward  and  toward  the  left,  until  it  reaches  the 
projecting  ridge  of  the  sacrum,  at  which  it  is  generally  arrested, 
when  it  should  be  withdrawn  a  few  inches,  and  while  it  is 
firmly  pressed  against  the  posterior  margin  of  the  anus,  it 
should  then  again  be  pressed  forward,  when  it  readily  ascends 
beyond  this  point  and  into  the  colon. 

It  is  the  opinion  of  some  surgeons  that  the  operation  of  in- 
troducing the  bougie  or  tube  into  the  sigmoid  flexure  of  the 
colon  is  highly  dangerous,  whilst  others  are  of  opinion  that  it 
cannot  be  done.  I  have  introduced  my  bougie  and  tube  with 
perfect  facility  six  inches  into  the  iliac  colon  in  numerous  in- 
stances, even  in  cases  in  which  there  was  more  or  less  disease 
of  some  of  the  parts  traversed  by  the  instrument,  and  I  have 
never  known  the  slightest  injury  or  inconvenience  to  result 
from  so  doing. 

I  prefer  the  bougie  or  the  tube  to  the  sound  for  exploring  the 
sigmoid  flexure  of  the  colon ;  indeed,  I  have  never  used  the 
rectal  sound  for  that  purpose,  but  have  confined  its  use  solely 
to  the  rectum. 

As  an  example,  however,  of  what  may  be  accomplished  by 
way  of  introducing  tubes  not  only  into  but  through  the  iliac 
colon,  and  even  into  the  right  lumbar  colon,  I  will  here  cite 
the  very  marvellous  case  reported  by  Professor  Storer,  of  a 
lady  who  was  suffering  from  ulceration  of  the  ascending  colon 
in  the  neighborhood  of  the  caecum.  In  this  instance  a  colonic 
tube  was  introduced  into  the  anus,  passed  up  the  rectum,  into 
and  on  through  the  sigmoid  flexure  of  the  colon,  up  the  de- 
scending colon,  across  the  transverse  colon,  and  down  the 
ascending  colon,  until  its  extremity  could  be  felt  by  external 
palpation  in  the  right  inguinal  region,  at  the  seat  of  the  dis- 
ease, after  having  traversed  a  distance  of  from  four  to  five  feet. 
Through  this  long  and  tortuous  tube  the  ingenious  Professor 


THE    PHYSICAL    EXPLORATION    OF    THE    RECTUM.  39 

injected  a  strong  solution  of  the  nitrate  of  silver.  The  manner 
in  which  this  wonderful  feat  was  accomplished,  is,  we  regret  to 
say,  entirely  left  to  conjecture.  (American  Journal  of  Ob- 
stetrics, Vol.  I.,  p.  Y4,  New  York,  1869.) 

5.  Particular  Directions  and  Precautions. — I  will  here 
refer  to  several  points  in  the  manipulation  that  must  be  ob- 
served in  the  introduction  of  the  sound,  bougie  or  tube  into 
the  rectum  and  sigmoid  flexure  of  the  colon. 

Great  care  is  necessary  to  keep  the  point  of  the  instrument 
always  moving  upward  in  the  axis  of  the  canal.  This  the  ex- 
perienced explorer  will  generally  be  able  to  decide,  merely 
from  the  sensation  communicated  to  his  hand.  We  can  only 
suppose  that  the  point  of  the  instrument  keeps  in  the  axis  of 
the  canal  by  the  facility  with  which  it  moves  on ;  and  the 
delicacy  of  touch  necessary  to  regulate  his  judgment  of  this 
will  be  entirely  lost,  if  the  instrument  is  too  firmly  grasped  by 
his  hand,  or  too  firmly  pressed  against  any  part  of  the  canal. 
No  force  should  therefore  be  employed  if  the  instrument  en- 
counters firm  opposition,  but  careful  pressure  may  be  main- 
tained for  a  few  seconds  ;  should  this  increase  the  pain,  how- 
ever, and  the  instrument  remain  stationary,  it  should  be 
withdrawn.  Occasionally  when  the  instrument  meets  with 
firm  opposition,  and  much  force  is  applied,  it  bends  upon 
itself,  and  communicates  to  the  inexperienced  hand  an  impres- 
sion that  it  has  passed  an  obstruction,  and  that  it  is  moving  on. 
When  such  is  really  the  case,  by  relinquishing  the  pressure 
entirely  from  the  instrument,  it  will  be  observed  to  slowly  recoil. 

Sometimes  the  point  of  the  instrument,  when  not  moving 
in  the  axis  of  the  canal,  becomes  hooked  in  the  lax  walls  of 
the  rectum  or  in  the  loose  folds  of  its  mucous  lining,  and 
pushes  up  before  it  the  same,  in  the  form  of  a  cul-de-sac,  so 
that  the  operator,  if  not  experienced,  will  be  apt  to  imagine 
he  has  encountered  a  stricture,  when  in  reality  none  exists. 
Indeed,  in  some  instances,  it  requires  considerable  adroitness 
to  prevent  the  intestine  from  being  thus  caught  up  in  sacs  by 
the  point  of  the  instrument,  and  requires  some  nicety  of  obser- 
vation to  distinguish  the  yielding  resistance  which  such  a  sac 
offers,  from  the  resistance  of  a  stricture.  However,  should  the 
opposition  experienced  be  a  sac  of  intestine  which  the  instru- 


40  THE    PHYSICAL    EXPLORATION    OF    THE    KECTUM. 

ment  has  temporarily  caused,  it  should  be  withdrawn  a  little, 
and  again  passed  up  gently,  with  its  direction  slightly  altered, 
and,  by  this  manosuvre,  it  will  keep  in  the  channel,  and  at 
least  not  sacculate  it  at  the  same  place.  Sometimes  the  bou- 
gie or  sound  comes  in  direct  and  firm  contact  with  the  promon- 
tory of  the  sacrum,  and  an  ignorant  operator  imagines  that 
this  also  must  be  a  stricture.  It  is  very  certain  that  occasion- 
ally practitioners  are  thus  misled,  and  assure  their  patients 
that  they  have  stricture  or  some  other  obstruction,  when  there 
is  none  whatever.  It  is,  useful  also  to  bear  in  mind  that  some- 
times a  mistake  may  occur  when  the  upper  part  of  the  intes- 
tine, being  distended  with  faeces,  is  forced  down,  and  to  a 
certain  extent  turned  upon  itself.  The  point  of  the  bougie 
being  directed  against  this  projecting  point,  may  also  give  rise 
to  the  idea  of  a  stricture. 

During  the  process  of  exploration,  violent  expulsive  efforts 
of  the  intestine  sometimes  take  place.  Should  these  occur,  it 
would  be  best  for  the  operator  to  yield  somewhat  to  them  by 
waiting  a  little,  and  then  to  take  advantage  of  their  intermis- 
sion in  order  to  pass  the  instrument  higher  up. 

In  very  delicate,  nervous  and  irritable  subjects,  especially  in 
those  in  whom  there  exists  more  or  less  irritation  or  chronic 
inflammation  of  the  mucous  membrane  of  the  rectum,  the 
introduction  of  the  sound,  bougie  or  any  instrumental  inter- 
ference, will  frequently  cause  an  irregular  spasmodic  action  of 
the  intestine,  and  consequently  its  sudden  contraction  upon 
the  instrument  at  different  points  in  its  passage.  The  con- 
stricting portion  will  often  be  found  to  vary  at  each  introduc- 
tion of  the  instrument.  On  one  day  it  will  be  found  at  one 
place,  whilst  on  another  at  quite  a  different  one.  Some  days 
it  will  be  entirely  absent,  whilst  on  others  it  will  be  much 
more  active  ;  all  depending  upon  the  health  and  peculiar  con- 
dition of  the  patient,  or  upon  vitiated  and  stimulating  secre- 
tions from  the  bowels.  This  condition  of  the  intestine  must, 
of  course,  be  first  corrected  by  judicious  remedies,  by  strict 
diet,  by  emollient  enemata,  &c.,  before  the  examination  can  be 
satisfactorily  determined.  The  spasmodic  actions  or  contrac- 
tions of  the  bowel,  in  some  instances,  continue  for  a  consid- 
erable length  of  time,  and  are  no  doubt  often  mistaken  for 
organic  or  permanent  stricture  of  the  rectum,  and  treated  as 


THE    PHYSICAL    EXPLORATION    OF    THE    RECTUM. 

such,  to  the  great  injury  and  inconvenience  of  the  patient. 
Such  cases  have  repeatedly  fallen  under  my  own  observation. 

In  the  withdrawal  of  the  instrument,  the  same  gentleness 
and  care  should  be  observed,  in  conducting  it  slowly  and  cau- 
tiously, as  in  its  introduction,  so  as  not  to  suffer  its  point  to 
strike  against  the  angles  of  the  intestine  or  against  the  bladder 
or  the  uterus. 

I  would  here  observe,  that  in  order  to  lessen,  as  far  as  prac- 
ticable, the  moral  and  physical  distress  that  are  the  ordinary 
accompaniments  of  sounding  the  rectum  in  females,  that  this 
operation  may  be  performed  under  the  bed  covering,  and  of 
course  without  the  least  exposure. 

In  conclusion,  I  would  remark,  that  when  the  bougie  or 
sound  meets  a  real  obstruction  in  the  rectum,  the  important 
fact  then  to  be  determined  is,  what  are  its  true  cause  and  na- 
ture. An  obstruction  of  this  intestine  may  arise  from  numer- 
ous and  various  causes.  It  may  be  a  spasmodic  or  a  perma- 
nent stricture,  adventitious  adhesions,  a  foreign  body,  an 
accumulation  of  hardened  faeces,  a  prolapsus  of  the  mucous 
lining,  a  tumor  or  tumors,  an  enlargement  of  the  prostate 
gland  ;  and  in  females  it  may  be  from  either  a  retroversion  or 
an  anteversion  of  the  uterus  encroaching  upon  some  point  or 
other  of  the  rectum,  or  from  an  enlargement  of  the  ovaries, 
pressing  upon  the  same,  &c.  The  qualified  surgeon,  however, 
when  he  meets  an  obstruction  or  a  resistance,  is  enabled  by  his 
anatomical  knowledge  at  once  to  comprehend  and  to  sur- 
mount it. 


APPENDIX. 


ON   THE 


LIGATION 

OF 

fL^MORRHOIDAL     TuMORS, 

BY 

WILLIAM   BODENHAMER,   A.M.,   M.D. 


ON  THE   LIGATTON 

OF 

HJIMOBRHOIDAL  TUMORS. 


[  Explanation.  The  following  article  was  originally  intended  for  publi- 
cation in  a  medical  periodical,  but  the  author  believing  that  if  it  had  any 
merit,  by  presenting  it  in  the  form  of  an  addendum  to  the  preceding  little 
work,  it  might,  perhaps,  prove  more  convenient  and  useful  to  the  student  ; 
he,  therefore,  determined  to  offer  it  to  the  profession  in  its  present  form.] 

At  a  meeting  of  the  New  York  Medical  Journal  Association, 
held  on  the  19th  of  March,  1869,  and  reported  in  the  Medical 
Record  of  October  1st,  1869,  page  356,  the  subject  of  ligating 
hsemorrhoidal  tumors,  was  introduced  by  Dr.  Post,  who  re- 
marked that — "  When  a  patient  from  the  country  could  stay 
but  a  week  or  two,  he  commonly  employed  the  ligature  instead 
of  the  nitric  acid,  for  the  removal  of  piles.  The  severe  pain 
attending  its  use  was  diminished,  by  having  the  ligature  very 
strong  and  drawing  it  very  tightly.  If  one  side  of  the  pile  was 
covered  with  skin,  it  might  be  well  to  incise  this,  though  it  was 
not  his  habit.  The  tumor  would  slough  off  in  a  week  or  ten 
days." 

Dr.  I.  E.  Taylor  said  that,  "  the  ligature  would  give  little 
pain,  if  it  included  only  mucous  membrane,  but  if  any  portion 
of  the  skin  were  included,  the  pain  would  be  severe." 

"  Dr.  Post  thought  the  mucous  membrane  more  sensitive 
than  that  of  almost  any  other  part." 

"  Dr.  Carroll  had  operated  on  a  lady,  where  the  pain  was  ex- 
cruciating until  the  ligature  came  away,  though  this  was  made 
as  tight  as  he  could  draw  it,  and  no  skin  whatever  was  included, 
the  tumor  being  quite  high  up.  The  patient  was  not  nervous, 
but  could  bear  pain  well." 


46  APPENDIX. 

"  Dr.  Ilubbard  described  Dr.  Dixon's  method  of  tying  piles, 
in  a  case  he  had  witnessed ;  and  Dr.  Carroll  remarked  that 
several  of  the  irregular  practitioners  had  some  peculiar  skill  in 
this  matter ;  an  acquaintance  of  his  had  his  piles  tied  by  one 
such,  with  no  pain  to  speak  of,  and  had  gone  regularly  to  his 
business  every  day  ;  the  operation  effected  a  cure." 

I  have  not  the  honor  of  being  a  member  of  the  "  New  York 
Medical  Journal  Association,"  and,  consequently,  can  only 
through  this  medium,  compare  my  own  observations  with  those 
of  some  of  its  members,  as  above  quoted.  I  would  here  remark, 
however,  so  as  not  to  be  misunderstood,  that  although  not  a  mem- 
ber, I  nevertheless  highly  approve  of  the  objects  of  that  society. 
Nothing  has  contributed  more  to  the  advancement  and  to  the 
elevation  of  the  science  of  medicine,  than  the  establishment  of 
well  regulated  medical  societies.  These  excite  a  generous 
ardor  and  rivalry  in  cultivated  and  liberal  minds,  and  rouse 
even  envy  itself  into  useful  emulation.  The  principal  part  of 
our  knowledge  must  ever  be  derived  from  comparing  our  own 
observations  with  those  of  others.  In  this  view,  the  utility  of 
medical  societies,  which  afford  an  opportunity  for  the  mutual 
communication  of  our  thoughts,  must  be  sufficiently  apparent. 
The  great  improvements  which  have  already  resulted  from  the 
formation  of  such  societies  are  well  known  to  the  medical 
world. 

The  declaration  made  by  Dr.  Carroll — that  several  of  the  ir- 
regular practitioners  of  our  city  have  some  peculiar  skill  or  know 
something  more  or  something  superior  in  relation  to  the  opera- 
tion of  ligating  hsemorrhoidal  tumors,  than  is  known  or  practiced 
by  members  of  the  regular  profession,  strikes  one  with  some 
surprise,  and  induces  one  to  ask  the  question,  why  is  this? 
Now,  taking  it  for  granted  that  this  is  so,  and  without  stopping 
to  answer  the  question,  why  it  is,  I  will  at  once,  with  a  view  to 
aid  in  removing  this  reproach  against  the  regular  profession, 
endeavor  to  contribute  my  mite  of  experience  upon  this  sub- 
ject, which  I  consider  an  important  one,  with  the  hope  that 
others  of  the  regular  profession,  especially  those  of  the 
"  Medical  Journal  Association  "  will  likewise  contribute  of  their 
abundance  to  the  same  end,  until  this  particular  stigma  upon 
the  escutcheon  of  our  profession,  shall  be  entirely  effaced.  This 
should  be  done  at  once,  for  the  operation,  as  before  remarked, 


ON   THE   LIGATION    OF    H^EMORRHOIDAL   TUMOKS.  47 

is  an  important  one  and  worthy  of  investigation,  and  one  which 
affords  much  scope  for  ingenuity ;  and  furthermore,  I  consider 
it  one  of  the  best  of  maxims,  that  every  man  should,  in  some 
way  or  other,  leave  the  world  benefitted  by  his  life. 

Having  been  in  the  constant  practice,  for  about  thirty  years, 
of  removing  hsemorrhoidal  tumors,  almost  exclusively  by  the 
silk  ligature,  I  have  necessarily  acquired  more  or  less  know- 
ledge and  experience  in  relation  to  the  operation.  In  my 
opinion,  if  it  is  judiciously  and  properly  performed,  it  is  the 
safest,  most  certain,  and  most  effectual  of  all  known  methods, 
and  this  opinion  is  now  gradually  becoming  the  settled  con- 
viction of  the  profession  at  large. 

The  old  method  of  tying  piles,  that  which  is  recommended 
in  the  books  taught  in  the  schools,  and  usually  practiced,  is 
(after  the  bowels  have  been  evacuated  and  the  tumors  pro- 
truded as  much  as  possible)  to  seize  each  tumor  by  either 
tenaculum  or  forceps,  and  draw  it  down  fully  out  of  the  anus, 
and  apply  closely  to  the  base  of  the  part  thus  drawn  down,  a 
strong  heavy  silk  or  hempen  cord,  and  then  the  same  drawn 
and  tied  as  tightly  as  can  be ;  or  a  curved  needle  armed  with 
a  double  ligature,  is  passed  through  the  base  of  the  tumor,  so 
as  to  divide  it  into  two,  and  the  cords  tied  as  tightly  as  pos- 
sible on  each  side.  After  the  tumors  are  all  tied,  they  are 
returned  within  the  anus,  and  an  enema  of  starch  and  lauda- 
num administered,  the  patient  required  in  the  meantime  to 
maintain  the  horizontal  posture,  to  live  on  meagre  diet,  and  to 
avoid  having  any  fsecal  evacuation  for  six  or  eight  days. 
Sometimes  immediately  after  tying  the  tumors,  they  are  then 
amputated  closely  to  the  ligature.  This,  in  short,  is  the  usual 
process  now  practiced  in  the  ligation  of  haemorrhoidal  tumors, 
and  from  the  very  nature  of  the  case,  must  necessarily  be  at- 
tended with  more  or  less  danger,  and  with  severe  pain  and 
inconvenience. 

The  great  objection  to  this  method  of  operating  is.  the  ex- 
treme suffering  which  follows  and  continues  for  a  considerable 
time,  and  the  confinement  to  either  bed  or  room  for  several 
days.  It  is  said,  too,  by  some  authorities,  that  the  operation  is 
attended  with  great  danger  from  tetanus,  phlebitis  or  pyaemia, 
&c.  This  danger,  however,  has  been  and  is,  in  my  opinion, 
greatly  exaggerated.  The  few  fatal  cases  reported  were  never 


48  APPENDIX. 

verified  by  a  post-mortem  examination,  and  consequently  are 
deserving  of  but  little  confidence.  I  believe  when  danger,  ex- 
treme pain  or  failure  attends  the  operation,  it  is  generally  re- 
ferrible  to  the  unsuitableness  of  the  ligature,  and  the  injudicious 
manner  in  which  it  has  been  placed  upon  the  tumor.  I  have, 
by  my  peculiar  method,  operated  in  thousands  of  instances, 
and  have  yet  to  encounter  the  first  serious  accident. 

The  circumstance,  then,  of  the  danger,  pain  and  inconve- 
niences attending  the  old  operation,  led  me,  about  twenty-five 
years  ago,  to  seek  for  information  in  relation  to  it,  with  a  view 
if  possible  to  remove  some  of  the  obnoxious  features  of  it,  or 
so  to  modify  it  as  to  make  it  less  objectionable  and  serious ; 
without  at  the  same  time  rendering  it  any  less  efficacious  in 
the  cure  of  the  disease.  I  first  began  by  making  some  experi- 
ments upon  both  internal  and  external  hsemorrhoidal  tumors, 
when  in  a  quiescent  state,  expressly  with  a  view  to  ascertain 
whether  any  one  point  or  portion  of  the  tumor  was  more  sen- 
sitive than  another  ;  and  more  especially  whether  the  mucous 
membrane,  or  other  tissue  from  which  such  tumor  proceeded,  was 
more  or  less  sensitive  than  the  tumor  itself  or  its  covering. 
The  experiments  were  conducted  by  means  of  a  peculiar  for- 
ceps, expressly  made  for  the  purpose.  The  apex  of  the  tumor 
was  first  seized  by  the  instrument,  and  firm  compression  made  ; 
the  middle  portion  next,  then  the  base,  and  lastly  a  portion  of 
the  lining  membrane  of  the  rectum,  to  which  the  tumor  was 
attached,  was  included  in  the  blades  of  the  forceps.  I  found 
that  in  proportion  as  the  compression  reached  the  base  of  the 
tumor  the  pain  was  increased,  and  when  a  portion  of  the  mu- 
cous membrane  of  the  rectum  or  other  tissue  was  included  in 
the  blades  of  the  forceps,  the  pain  was  very  severe.  I  have 
ever  since,  in  operating,  been  very  careful  so  to  adjust  the  liga- 
ture as  not  to  tie  it  too  close  to  the  base,  and  that  nothing  but 
the  tumor  itself  should  be  included  in  its  grasp.  Now  the 
question  naturally  arises,  what  is  the  cause  of  this  difference  in 
the  sensibility  of  the  natural  textures  from  which  the  tumor 
proceeds,  and  those  of  the  tumor  or  foreign  growth  itself? 
The  most  rational  inference  which  occurs  to  my  mind  at  pres- 
ent is,  that  the  former  are  more  abundantly  supplied  with 
nerves  and  nervous  influence  than  the  latter.  Be  this  as  it 
may,  however,  the  fact  is  as  I  have  stated  it,  and  it  is  in  the 


ON  THE   LIGATION   OF    H.EMORRHOIDAL    TUMORS.  49 

power  of  any  student  to  verify  it.  But  on  this,  as  on  many 
other  points  of  pathology  and  physiology,  we  are  sometimes 
much  better  acquainted  with  the  quo  than  with  the  quomodo  / 
In  other  words,  we  know  the  facts,  but  we  cannot  well  explain 
them.  My  researches  on  this  subject  have  plainly  taught  me 
that  so  far  as  the  natural  tissues  are  concerned,  the  fine  and 
delicate  skin  immediately  without  the  anal  orifice  is  the  most 
sensitive;  that  the  muco-cutaneous  coat  immediately  within 
the  anal  orifice  is  next  in  point  of  sensibility,  and  that  the 
mucous  membrane  of  the  rectum  is  the  least  sensitive  of  the 
three.  I,  therefore,  do  not  agree  with  Dr.  Post,  when  he  says 
he  thinks  the  mucous  membrane  more  sensitive  than  that  of 
almost  any  other  part.  I,  however,  have  found  the  mucous 
membrane  of  the  rectum  much  more  sensitive  than  the  mucous 
membrane  covering  the  tumor.  This  must  not  be  forgotten. 
Indeed  the  foreign  body  and  its  covering,  unless  entirely  ex- 
ternal and  covered  with  true  skin,  are  much  less  sensitive  than 
the  three  natural  textures  previously  named. 

I  now  propose  to  offer  some  improvements  in  the  operation 
of  ligating  haemorrhoidal  tumors,  the  success  of  which  has 
been  invariable,  and  warranted  by  an  experience  of  upwards 
of  twenty-five  years. 

By  my  method  of  operating,  the  tumor  to  be  ligated  is 
never  seized  by  tenaculum  nor  forceps,  and  pulled  down ;  for 
if  this  is  done,  a  portion  of  the  elastic  mucous  membrane  of 
the  rectum,  to  which  the  tumor  adheres,  also  comes  down  with 
it,  and  therefore  is  almost  certain  to  be  included  in  the  grasp 
of  the  ligature — hence  the  additional  pain  and  suffering  which 
necessarily  follow;  for  the  operator  caunot  distinguish  the 
true  base  of  the  tumor  from  any  other  part  when  drawn  down 
in  this  manner,  for  all  the  parts  generally  have  the  same  ap- 
pearance. I  always  require  my  patients  to  extrude  the  tumors 
simply  by  defecating  efforts,  or  by  the  efforts  produced  by 
means  of  an  aperient  or  a  relaxing  enema.  If  one  or  all  these 
means  should  fail  to  protrude  the  tumors,  I  employ  a  bi-valve 
speculum  ani,  introducing  and  arranging  it  in  such  manner 
that  the  tumor  which  I  design  to  ligate  should  fall  between 
its  blades ;  then,  with  suitable  instruments,  it  can  be  ligated 
within  the  canal,  just  as  easily  as  if  it  were  extruded  or  exter- 
nal. I  scarcely  ever  take  up  more  than  one  tumor  at  one  time, 


50  APPEITDIX. 

and  never  employ  a  heavy  silk  cord  with  a  hard  twist  in  it, 
such  as  saddler's  silk,  which  is  the  article  often  used  for  this 
purpose,  but  use  a  fine  silk  ligature,  well  waxed,  with  scarcely 
any  twist  in  it,  somewhat  like  floss  or  dentist's  silk ;  for  in 
proportion  to  the  size  of  the  ligature  and  the  hard  twist  in  it, 
will  be  the  increased  pain  it  will  occasion,  and  the  length  of 
time  it  will  take  the  tumor  to  slough  off.  As  before  observed, 
I  am  careful  so  to  adjust  the  ligature  as  to  exclude  everything 
but  the  foreign  body  itself,  and  only  make  the  ligature  suffi- 
ciently tight  to  cut  off  the  circulation — nothing  more  nor  less. 
This  can  be  known  and  adjudged  by  the  appearance  of  the  tu- 
mor whilst  the  ligature  is  being  tightened.  I  am  also  careful 
not  to  place  the  ligature  very  close  to  the  base  of  the  tumor,  as 
this  produces  more  pain,  and  is  not  any  more  effectual  in  re- 
moving the  whole  of  it.  The  small  portion  of  the  base  of  the 
tumor  below  the  ligature,  will  also  sooner  or  later  completely 
slough  off.  When  the  tumor  is  very  large,  or  too  large  for  one 
ligature,  I  divide  it  into  two  or  more  sections,  according  to  its 
size,  and  multiply  the  ligatures,  including  but  a  small  portion 
of  the  tumor  in  each.  This  is  done  by  arming  a  suitably 
curved  needle  with  a  double  ligature,  passing  it  through  the 
base  of  the  tumor,  and  if  necessary  repassing  it,  and  tying 
each  ligature  separately — thus  including  in  the  stitches  every 
part  of  the  tumor,  and  underlaying  it,  as  it  were,  with  a  double 
uninterrupted  suture.  When  part  of  the  tumor  is  covered 
with  true  skin,  or  muco-cutaneous  tissue,  I  usually  incise  this 
upon  the  same  circle  which  is  to  receive  the  ligature  afterwards, 
by  which  more  or  less  suffering  is  avoided.  I  sometimes,  when 
the  tumor  is  entirely  external  and  covered  with  true  skin,  and 
objection  made  to  the  knife  or  curved  scissors,  ligate  it  subcu- 
taneously,  which  causes  it  to  shrivel  and  gradually  to  disappear. 
By  this  operation  the  integument  is  not  interfered  writh,  and 
much  pain,  suffering  and  inconvenience  from  the  ligature  other- 
wise applied  are  avoided.  The  subcutaneous  ligation  of  ex- 
ternal haemorrhoids,  consists  in  encircling  the  base  of  the  tumor 
with  a  ligature  passed  immediately  beneath  the  skin.  This  is 
accomplished  by  the  use  of  a  proper  needle,  describing  a  con- 
siderable curve,  and  with  it  to  puncture  the  tumor  at  a  suitable 
place,  and  to  carry  a  ligature  subcutaneously  half  round  the 
same.  The  needle  is  then  to  be  brought  out  at  this  point,  and 


ON   THE    LIGATION    OF    HJEMORRHOIDAL    TUMORS.  51 

re-introduced  at  the  point  of  exit,  and  carried  round  the  other 
half  to  the  original  point  of  entrance,  and  then  tied.  If  the 
tnraor  is  large  it  may  be  divided  into  two  or  more  sections  as 
before  described.  This  is  the  operation  which  is  sometimes 
employed  for  the  removal  of  naevi. 

The  modus  operandi  of  the  ligature  is  this — it  removes  the 
tumor  or  foreign  growth  by  two  processes  :  first,  by  depriving 
it  of  its  due  supply  of  blood,  and  secondly,  by  making  its  way 
through  the  base  of  the  tumor  by  ulcerative  absorption.  Now, 
while  it  is  obvious  that  the  first  of  these  effects  may  be  accom- 
plished by  the  application  of  the  finest  and  softest  ligature,  it 
is  equally  clear  that  the  larger  and  harder  the  substance  of  the 
ligature  is,  the  longer  the  time  it  will  take,  and  the  more 
extensive  the  inflammation,  pain  or  irritation  it  will  produce  in 
accomplishing  the  second.  I  repeat,  then,  that  when  a  strong 
silk  cord  is  used  as  a  ligature,  which  is  comparatively  a  rough 
substance,  especially  when  hard  twisted,  it  will,  by  its  mechan- 
ical attrition,  produce  more  inflammation  and  pain,  and  con- 
tinue them  longer,  than  when  the  ligature  is  finer,  softer,  not 
much  twisted  and  not  drawn  too  tightly.  I  therefore  again 
disagree  with  Dr.  Post,  who  maintains  that  "  the  severe  pain 
attending  the  use  of  the  ligature  is  diminished  by  having  it 
very  strong  and  drawing  it  very  tightly."  Sir  Astley  Cooper 
says  that  the  pain  which  the  ligature  produces  may  be  miti- 
gated by  not  drawing  it  too  tight.  This  excellent  advice, 
however,  is  liable  to  be  abused,  inasmuch  as  it  is  not  sufficiently 
definite.  The  ligature  must  be  drawn  tight  enough  to  inter- 
rupt all  kind  of  circulation  and  physiological  action  in  the 
tumor ;  if  this  is  not  accomplished,  the  tumor  will  not  perish, 
or  perish  very  slowly,  and  more  or  less  sensibility  will  remain 
in  it.  The  desirable  end,  the  complete  destruction  of  the 
tumor,  can  be  attained,  however,  without  making  the  ligature 
as  tight  as  it  can  be.  The  amount  of  strangulation  should  be 
just  sufficient  to  arrest  the  passage  of  the  fluids.  The  tumor, 
thus  deprived  of  its  vitality,  first  becomes  blue  or  livid,  and 
then  softens,  shrinks  and  loses  its  volume,  and  acts  in  the  same 
manner  as  any  dead  foreign  body  which  must  necessarily  come 
away  through  the  eliminating  powers  of  the  system.  When 
the  entire  physiological  circulation  of  the  tumor  is  suspended 
for  twenty-four  hours,  the  principal  object  of  the  operation  is 


52  APPENDIX. 

attained.  After  this,  the  final  result  will  be  the  same,  whether 
the  ligature  remains  on  till  the  tumor  drops,  comes  off  acci- 
dentally, or  is  intentionally  removed.  "When  there  is  pain, 
after  a  certain  period,  the  pain  is  not  in  the  tumor  itself,  but 
in  the  contiguous  natural  textures  not  included  in  the  grasp 
of  the  ligature. 

As  true  haeinorrhoidal  tumors  vary  in  locality,  structure, 
numbers,  size,  vascularity,  sensibility,  <fec.,  so  do  they  require 
modifications  of  treatment.  Those  in  which,  more  than  any 
others,  ligation  is  more  especially  indicated,  are  the  internal 
ones,  which  are  florid,  soft  and  highly  vascular,  which  protrude 
readily  and  bleed  freely ;  also  those  internal  ones  which  are 
indurated,  dark,  firm,  with  little  sensibility,  protruding  at 
each  evacuation,  and  attended  with  a  free  mucous  discharge. 
Those  round  and  sometimes  blue  tumors,  located  at  the  mar- 
gin of  the  anus,  and  covered  partly  with  mucous  and  partly 
with  muco-cutaneous  tissue,  should,  when  large,  be  ligated, 
after  incising  that  part  covered  with  the  muco-cutaneous  tis- 
sue. When  any  of  these  are  very  small  and  quiescent,  they 
may  be  let  alone,  but  when  any  of  these  small  ones  are  hard, 
distended  and  painful,  they  should  be  punctured  with  a  lancet 
and  their  contents  completely  let  out.  Those  tumors  that  are 
altogether  external,  or  completely  without  the  anus,  and  cov- 
ered with  true  skin,  should  be  removed  by  the  knife  or  curved 
scissors,  or  ligated  sub-cutaneously. 

I  am  never  in  the  habit  of  ligating  haemorrhoids  when  they 
are  in  an  irritable  or  inflamed  condition,  but  wait  until  the 
irritability  or  inflammation  has  spontaneously  subside!,  or  has 
been  subdued  by  proper  treatment.  It  often  occurs,  that 
among  several  tumors  which  are  in  a  quiescent  state,  there 
will  be  found  one  highly  sensitive  and  irritable.  This  one 
may  be  easily  distinguished  from  the  rest  by  its  florid  appear- 
ance, or  by  its  being  tense,  tender  and  painful  upon  pressure. 
If  the  operation  is  performed  when  the  tumor  or  tumors  are 
irritable  or  inflamed,  the  pain  and  suffering  will  be  greatly 
augmented.  I  sometimes  remove  the  inflammation,  the  irrita- 
bility or  the  sensibility  of  the  tumor  or  tumors  by  the  applica- 
tion of  a  solution  of  the  nitrate  of  silver,  applied  by  means  of 
a  camel-hair  pencil,  and  immediately  after  apply  olive  oil  to 
the  same.  Two  or  three  of  these  applications  in  as  many  days 


ON   THE    LIGATION    OF    H.EMORRHOIDAL   TUMORS.  53 

are  usually  sufficient.  The  solution  should  be  of  such  strength 
as  not  to  produce  a  slough,  not  to  abrade  or  to  injure  the  sur- 
face. All  that  is  required  is  the  sedative  power  of  the  caustic, 
without  its  injurious  effects.  If  applied  of  a  certain  strength, 
say  from  ten  to  fifteen  grains  of  the  crystals  to  one  ounce  of 
distilled  rose  water,  it  will  diminish  the  sensibility  and  irrita- 
bility in  a  most  remarkable  manner.  The  patient,  in  the 
meantime,  should  live  on  bland  and  unirritating  diet,  and  his 
bowels  should  be  relieved  entirely  by  enemata  of  the  infusion 
of  linseed,  to  which  a  little  castor  or  olive  oil  should  be  added. 

Now,  if  what  I  have  stated  in  relation  to  the  ligation  of 
hsemorrhoidal  tumors  be  true,  and  the  statements  can  easily  be 
verified  by  competent  persons,  my  method  of  operating  is  far 
superior  to  that  practiced  by  surgeons  generally,  and  at  least 
equal,  if  not  superior  to  that  practiced  by  some  of  the  irregular 
practitioners  mentioned  by  Dr.  Carroll.  It  is  much  safer,  very 
much  milder,  and  equally  as  certain  and  effectual.  It  is  sel- 
dom that  my  patients,  during  the  whole  course  of  treatment, 
are  ever  confined  for  a  moment  to  either  their  rooms  or  their 
beds,  but  are  enabled  at  all  times  to  be  up  and  attend  to  ordi- 
nary business. 

Very  much  might  be  said  profitably  in  drawing  a  parallel 
between  ligation  on  the  one  hand,  and  the  several  surgical 
measures  adopted  for  the  removal  of  hsemorrhoidal  tumors,  on 
the  other — such  as  excision  by  knife  or  scissors,  ecrasement, 
the  actual  cautery,  the  potential  cautery,  Dupuytren's  combi- 
nation of  forceps,  scissors  and  actual  cautery  ;  the  same  modi- 
fied by  Mr.  Smith,  of  London,  of  clamp  and  knife  or  scissors, 
and  actual  or  potential  cautery ;  M.  Amussat's  method  of 
clamp  and  caustic  potash ;  Houston's  method  of  nitric  acid  ; 
the  galvano-caustic  method  of  Middledorpff ;  and  the  method 
of  M.  Richet,  of  cauterizing  the  tumor  in  several  sections  by 
means  of  a  peculiar  forceps  brought  to  a  white  heat ;  all  of 
which  find  advocates  in  able  authorities ;  but  this  article  is 
already  extended  much  further  than  at  first  designed.  I  can- 
not, however,  resist  making  one  single  remark  more,  by  way 
of  conclusion.  That  is,  that  thousands  of  persons  who  are 
daily  suffering  from  this  affection,  who  should  at  once  undergo 
surgical  or  radical  treatment  for  the  same,  are  deterred  from 
so  doing  from  a  great  dread  they  have  of  the  formidableness, 


54  APPENDIX. 

severity  and  danger  of  the  operations  ;  or  from  a  belief  they 
entertain  that  this  disease  can  never  be  radically  cured  ;  or  that 
it  is  salutary  and  designed  to  ward  off  some  other  more  serious 
affection,  and  therefore  should  not  be  cured  ;  or  that  it  is  never 
local,  but  always  constitutional,  and  cannot  be  cured  by  any 
local  measure,  &c. — hence  such  patients,  receiving  but  little 
information  and  encouragement  from  the  regular  profession, 
many  of  whom  themselves  entertain  similar  erroneous  notions, 
generally  fall  into  the  hands  of  empirics  or  irregular  practition- 
ers, or  are  in  the  constant  use  of  some  of  the  one  thousand  and 
one  quack  remedies  found  in  the  drug  shops,  and  recommended 
in  the  papers,  or  by  some  of  their  numerous  kind  friends.  Let 
it  then  be  our  united  aim  to  rescue  this  affection  from  out  of 
the  hands  of  the  quacks,  who  have  too  long  already  monop- 
olized it,  to  the  exclusion  and  the  disgrace  of  the  regular 
profession. 

237.  Fifth  Avenue,  New  York. 


[By  the  same  Author.] 

PRACTICAL  OBSERVATIONS  ON  THE  AETIOLOGY, 
PATHOLOGY,  DIAGNOSIS,  AND  TREATMENT 

OP 

-A.:tT.A_I_,     IE1 1  S  S  TT IR,  IE  . 

Illustrated  by  numerous  Cases  and  Drawings. 

In  one  neat  8vo.  volume,  bound  in  extra  muslin.  Price,  $2.25  by  mail, 
free  of  postage. 

WM.  WOOD  &  CO.,  Publishers, 

61  Walker  Street,  New  York. 

JSOTICEB  OF  THE  MEDICAL  PRESS. 

"  Dr.  Bodenhamer  is  already  well  and  favorably  known  in  the  department 
of  practice  to  which  this  book  refers,  as  the  author  of  the  most  complete 
treatise  in  existence  on  the  malformations  usually  classed  together  as 
'  Imperforate  Anus.'  The  present  volume  equals  that  mom 'graph  as  an 
exhaustive  statement  of  the  matter  to  which  it  refers.  *  *  *  * 
After  a  minute  and  very  good  and  accurate  account  of  the  symptoms  and 
diagnosis  of  anal  fissure,  the  author  proceeds  to  detail  the  treatment  appro- 
priate to  the  different  forms  of  the  disease.  We  can  only  quote  here  the 
brief  description  given  in  the  table  of  contents  of  '  the  treatment  as  pursued 
by  the  author.'  "  It  consists  of  topical  medication  combined  with  dilatation, 
and  sometimes  scarification  or  incision  of  the  mucous  membrane.  The  chief 
indication  is  to  modify  the  surface  of  the  ulcer,  and  transform  it  into  a  simple 
or  common  sore."  For  the  methods  by  which  Dr.  Bodenhamer  endeavors  to 
fulfill  these  indications,  as  well  as  for  the  elaborate  review  which  he  gives  of 
the  treatment  recommended  by  others,  we  must  refer  to  the  original.  Its 
perusal,  or  rather  its  study,  will  be  found  highly  remunerative  by  all  who 
have  much  opportunity  of  treating  the  affections  of  the  rectum." — British 
and  Foreign  Medico-Chirurgical  Review. 

"  In  this  monograph  of  one  hundred  and  ninety-two  pages,  the  author  gives 
not  only  the  literature  of  the  subject,  but  presents  the  conflicting  opinions  of 
eminent  surgeons,  from  the  time  of  Boyer  to  the  present  day,  in  regard  to  the 
pathology  and  treatment  of  anal  fissure. 

"  He  demonstrates  clearly,  by  clinical  records,  the  relation  existing  between 
anal  fissure  and  spasm  of  the  sphincters,  taking  the  opposite  views  to  the  one 
entertained  by  Boyer  and  others.  He  considers  the  anal  spasm  the  result  of 
the  anal  fissure.  '  This  spasmodic  contraction,'  he  writes,  '  is  a  phenome- 
non which  may  or  may  not  accompany  fissure  of  the  anus.  It  is  not  the 
anal  spasm  that  constitutes  the  disease,  for  anal  fissure  may  exist  without 
this  arbitrary  contraction  ;  but  such  contraction  of  the  sphinctores  am  never 
exists  without  an  irritable  fissure,  an  inflammation,  tumefaction  or  some  other 
primary  disease  of  the  inferior  extremity  of  the  rectum ;  or  of  some  disease 
of  the  genito-urinary  organs.' 

"  The  importance  of  this  view  of  the  pathology  of  the  disease  is  not  less 
striking  than  the  revolution  in  the  treatment  which  must  necessarily  result 
from  it.  For  while  Boyer  and  Dupuytren,  Brodie  and  others,  regarding  the 
spasm  as  a  primary  and  essential  condition,  deemed  incision  or  rupture  of 
the  sphincter  necessary  for  the  radical  cure  of  the  ulcer,  the  author,  on  the 
other  hand  has  succeeded  uniformly  in  effecting  cures  without  so  severe  a 
procedure.  He  employs  the  knife  only  in  very  intractable  cases,  and  then 
only  to  the  extent  of  dividing  the  mucous  membrane  through  the  long  axis 
of  the  fissure. 

"  The  author  divides  the  various  kinds  of  fissure  into  classes  according  to 
the  site  of  the  disease,  viz. :  (1)  Those  on  the  outside  of  the  anal  orifice  ; 
(2)  those  immediately  within  the  anal  orifice  ;  (3)  those  situated  above  the 
external  sphincter;  (4)  those  situated  on  and  a  little  above  the  internal 
sphincter. 


"  His  description  of  the  signs  and  symptoms,  rational  and  physical,  his 
enumeration  of  the  minute  details  of  an  examination  per  rectum  wither  with- 
out instruments,  and  of  the  various  points  to  be  observed  in  order  to  accom- 
plish a  speedy  and  permanent  cure  with  the  least  amount  of  pain,  are  con- 
cise and  graphic.  The  reader  will  perceive  throughout  the  whole  work 
marked  evidences  of  close  clinical  observation,  respect  for  the  opinions  of 
others,  the  absence  of  dogmatism  and  a  desire  to  impart,  without  reserve,  full 
measure  of  the  author's  knowledge  of  a  disease  with  which  he  has  grown 
familiar  by  years  of  experience. 

"  It  would  be  impossible  to  do  full  justice  to  the  merit  of  this  little  work, 
without  making  a  full  review  of  it.  Those  practitioners  who  read  it  will  find 
many  useful  hints  to  guide  them  in  the  diagnostication  and  treatment  of  this 
painful  and  obstinate  malady. 

"  The  work  is  illustrated  by  a  number  of  well  executed  drawings,  and  by 
twenty-nine  type  cases  of  the  disease." — Richmond  and  Louisville  Medical 
Journal. 

"  In  this  book  of  192  pages,  we  find  a  complete  resume  of  the  subject  of 
Fissure  of  the  Anus,  its  Anatomy,  Physiology,  Symptomatology,  and  Treat- 
'ment.  The  author  quotes  the  opinions  of  different  authors  upon  the  various 
points  discussed,  referring  in  an  extensive  bibliographical  section  to  the 
original  sources  of  his  information. 

"  His  own  views  are  nevertheless  expressed  with  independence  and  clearness 
and  his  principal  points  of  difference  are  defended  and  supported  with  appar- 
ent candor,  and  in  a  fair  logical  manner.  The  style  of  the  author  is  rather 
pointed  and  forcible,  of  the  two  calculated  perhaps  to  impress  more  than  to 
convince.  The  method  is  good  and  the  arrangement  of  the  book  convenient. 

"  The  existence  of  spasmodic  contraction  as  '  an  entity  '  is  disputed.  In 
cases  supposed  to  be  of  this  nature  the  author  thinks  its  cause  is  always  due 
to  a  fissure  or  ulcer  undetected. 

"  A  fissure  of  the  anus  is  described  as  a  superficial  breach  of  the  surface  in 
the  anal  region,  of  a  highly  sensitive,  irritable,  or  painful  character,  of  what- 
ever shape.  The  various  theories  advanced  in  explanation  of  the  interval 
between  evacuation  and  the  characteristic  accession  of  pain  in  the  fissure 
are  ably  discussed.  That  of  Dr.  Van  Buren  seems  to  be  fairly  refuted,  though 
the  author  frankly  confesses  his  own  incompetence  to  substitute  one  satis- 
factory to  himself.  Objection  is  made  to  the  treatment  of  fissure  by  Beyer's 
method,  viz.,  the  complete  division  of  the  sphincter,  as  also  to  the  method 
first  recommended  and  practiced  by  Nelaton,  by  forcible  dilatation  and  rup- 
ture with  the  thumbs. 

"  The  author's  treatment  consists  mainly  of  the  topical  use  of  nitrate  of 
silver  combined  with  dilatation  without  rupture  of  the  sphincter,  with  the 
addition  sometimes  of  scarification  and  incision  of  the  mucous  membrane. 
The  objects  sought  are  to  change  the  character  of  the  ulcer  to  a  simple  sore, 
and  to  secure  rest  so  that  it  may  heal  without  disturbance.  It  is  alleged  that 
this  treatment,  though  apparently  only  palliative,  is  sufficient  to  induce  a 
complete  and  satisfactory  cure  in  the  large  majority  of  cases  ;  in  proof  of  which 
twenty-nine  cases  with  their  histories  are  appended.  This  book  is  a  credit 
to  its  author.  It  is  a  clear,  succinct,  and  complete  summary  on  the  question 
up  to  the  present  date." — Medical  Record,  New  York. 

"  The  author  of  this  monograph  is  already  favorably  known  by  his  work 
on  '  Congenital  Malformations  of  the  Rectum  and  Anus,'  published  some 
years  since.  The  class  of  diseases  to  which  he  has  given  his  attention  is  by 
no  means  small,  and  counts  some  of  the  most  annoying  to  which  the  human 
frame  is  subject.  What  is  more,  owing  to  a  false  delicacy,  sometimes  on  the 
part  of  the  patient,  sometimes  on  that  of  the  doctor,  they  are  frequently 
overlooked  or  misunderstood. 

"  The  first  chapter  treats  of  the  history  of  anal  fissure,  and  of  its  very 
troublesome  concomitant  spasmodic  contraction  of  the  anus  ;  the  second  ex- 
amines into  the  name  fissura  ani,  and  the  physiology  of  the  complaint ;  its 
aetiology,  in  which  constipation  has  a  prominent  share,  comes  next,  and  then 
a  classification  and  description  of  the  various  varieties  of  fissure,  their  symp- 
toms and  signs,  diagnosis  and  prognosis.  The  fifth  chapter  gives  at  consid- 


erable  length  the  different  methods  of  treatment,  and  the  sixth  and  conclud- 
ing chapter  presents  a  variety  of  illustrative  cases,  of  no  little  clinical  value. 
A  short  bibliography  is  appended. 

"  The  treatise  is  throughout  carefully  prepared,  and  we  recommend  it  as  a 
valuable  practical  book,  worth  a  place  in  any  working  library." — Medical 
and  Surgical  Reporter,  Philadelphia. 

"  The  large  number  of  cases  of  Anal  Fissure  which  are  unrecognized 
and  which  are  either  improperly  treated  or  not  treated  at  all,  is  sufficient 
excuse  for  an  attempt  to  enlighten  the  profession  upon  their  diagnosis 
and  management.  This  Dr.  Bodenhamer  has  done,  and  we  think  well 
done.  The  opening  chapters  of  his  monograph  are  devoted  to  the  patho- 
logical conditions  involved,  with  copious  references  to  the  opinions  held 
by  the  older  and  by  contemporary  surgeons.  These  are  succeeded  by 
sections  devoted  to  the  ^Etiology  and  Diagnosis  of  the  affection  and  the 
physical  exploration  of  the  lower  part  of  the  Rectum.  The  affection,  as 
most  are  aware,  consists  in  an  Ulcer  or  Fissure  of  the  mucous  membrane 
of  the  lower  portion  of  the  Rectum,  or  verge  of  the  anus,  and  frequently 
accompanied  with  an  irritable  or  spasmodic  condition  of  the  Sphincter 
muscles.  The  author  recommends  the  application  to  the  Ulcers  or  Fissures 
of  active  stimulants,  such  as  the  solid  Nitrate  of  Silver,  the  Acid  Nitrate 
of  Mercury,  &c.,  together  with  gradual  dilatation  by  means  of  Rectal  Bou- 
gies, believing  that  with  these  simple  measures  he  will  succeed  in  the 
vast  majority  of  cases,  and  render  unnecessary  division  of  the  sphincters 
or  their  forcible  dilatation.  The  volume  concludes  with  an  extended  list 
of  cases  treated  by  him  and  a  Bibliographical  appendix." — Medical  Ga- 
zette, New  York. 

"  There  are  few  physicians  of  any  considerable  experience  who  have  not 
encountered,  more  or  less  frequently,  cases  of  this  diminutive,  but  horribly 
painful,  wearing  and  often  very  grave  malady.  Those  who  have  met  them, 
and  have  realized  the  excruciating  nature  of  the  disease  and  the  frequency 
with  which  it  defies  all  ordinary  means  of  treatment,  cannot  be  but  gratified 
with  the  perusal  of  this  little  volume. 

"  The  author  has  devoted  some  twenty-five  years  to  the  investigation  of 
the  diseases  of  the  rectum  and  anus,  and  speaks  with  the  tone  of  a  master. 
It  is  surprising  that  so  much  can  be  said  on,  apparently,  so  small  a  matter. 
The  author  gives  the  bibliography  of  the  disease,  from  the  first  recorded 
observations  to  his  own  contemporary  writers,  together  with  the  various 
methods  of  treatment  which  have  from  time  to  time  obtained,  adding  his 
own  experiences  and  practice,  and  illustrating  them  with  full  records  of 
cases. 

"  We  welcome  the  appearance  of  such  works,  as  all  practitioners  must, 
who  having  cases  to  treat  of  small  diseases,  find  so  little  information  and 
satisfaction  in  the  general  text  books,  where  they  are  often  run  over  in  a  few 
lines.  We  hope  the  day  will  come  when  only  text  books  on  the  general 
history  and  principles  of  disease  will  be  written,  and  the  consideration  of 
special  diseased  action  will  be  left  to  monographs  or  articles  in  a  standard 
encyclopaedia  of  medicine. 

"  There  are  grave  consequences  sometimes  attending  some  of  the  recom- 
mended methods  of  treating  anal  fissure,  as  that  of  rupturing  the  sphincters 
by  forcible  dilatation,  and  it  would  be  well  for  all  physicians,  at  least  before 
resorting  to  any  operative  procedures  for  relief,  to  read  this  little  work  of 
Dr.  Bodenhamer." — Leavenworth  Medical  Herald. 

"  We  have  space  but  to  notice  the  reception  of  this  work,  and  will  review 
it  in  a  future  number.  To  those  who  are  interested  in  the  subject,  however, 
we  may  say  that  it  is  very  thorough  and  explicit." — Eclectic  MtdicalJournal 

"  After  a  lengthy  historical  introduction,  the  author  treats  first  of  the  phy- 
siology and  aetiology  of  this  affection,  which  he  ascribes  to  spasms  and  to 
constipation.  Next  he  describes  the  symptoms  and  diagnosis  ;  and  finally, 
the  treatment  of  anal  fissure.  The  different  methods  are — Topical  applica- 
tions, cauterization,  dilatation,  incision,  excision  and  complete  division  of  the 
sphincter.  A  chapter  of  illustrative  cases  completes  the  work,  which  is  a 


very  complete  treatise  on  this  painful  affection." — Boston  Medical  and  Surgi- 
cal Journal. 

"  Judging  from  the  works  before  us,  Dr.  Bodenliamer  is  one  of  those  whose 
labors  are  now  most  wanted  in  the  profession.  It  has  become  too  much  the 
fashion  to  write  books  ostensibly  to  advance  medical  science,  in  reality  to 
subserve  the  personal  interests  of  their  authors.  Selecting  a  neglected  field, 
Dr.  Bodenhamer  has  gone  to  work  with  great  industry  and  patience,  with  no 
•  special'  treatment  to  present,  no  novel  operations  to  suggest,  but  chiefly  to 
gather  from  all  quarters  material  for  its  illustration,  and  to  put  it  in  order 
for  more  general  usefulness.  While  clear  in  the  expression  of  his  own  opin 
ions,  he  has  not  made  a  book  merely  to  enunciate  or  support  them. 

"  The  treatise  on  the  Malformations  of  the  Rectum  and  Anus  is  the  most 
elaborate  monograph  upon  the  subject  within  our  knowledge.  Arranging 
under  appropriate  heads  the  varieties  of  these  malformations,  our  author  di- 
vides them  into  nine  species,  each  of  which  is  fully  described,  with  its  treat- 
ment, and  illustrated  by  cases  drawn  from  all  sources.  The  cases  reported 
amount  to  two  hundred  and  eighty-seven,  embracing  many  of  interest.  A 
chapter  on  Abdominal  Artificial  Anus  appropriately  concludes  the  subject. 
The  book  is  also  illustrated  by  sixteen  finely-executed  plates. 

"  The  work  on  Anal  Fissure  is  not  so  free  from  the  '  personality  '  of  the 
author  as  the  one  just  spoken  of,  the  cases  in  his  own  practice  being  some- 
what ostentatiously  given.  A  criticism  might  also  be  made  upon  the  size  of 
the  work,  as  evidencing  too  much  diffuseness,  but  the  care  and  completeness 
with  which  the  subject  has  been  treated  are  so  evident,  that  possibly  any 
attempt  to  condense  would  have  impaired  the  value  of  the  book  as  a  thorough 
treatise." — The  Baltimore  Medical  Journal. 


\JBy  the  same  Author.  .] 

A    PRACTICAL    TREATISE    ON   THE   AETIOLOGY, 

PATHOLOGY,  AND  TREATMENT  OF  THE 

CONGENITAL  MALFORMATIONS 


HECTTJM   ^.ND   A.NTJS. 

8vo.     16  Plates.     Price  $4,  free  of  postage. 

WILLIAM  WOOD  &  CO., 

61  Walker  Street,  New  York. 

NOTICES  OF  THE  MEDICAL  PRESS. 

"  This  work  constitutes  one  of  the  most  complete  monographs  with  which 
we  are  acquainted.  In  it  we  have  collected,  and  apparently  with  accuracy, 
no  less  than  287  cases,  from  every  available  source,  and  also  a  review  of  both 
the  medical  and  surgical  treatment  in  full  from  the  earliest  times,  with  all 
the  improvements  down  to  the  present  time." 

"  The  iraterials  collected  and  introduced  into  the  work  are  well  digested, 
with  full  and  particular  references  to  their  sources  ;  and  in  the  relation  of  the 
various  cases,  the  remarks  of  the  original  writers  are  given  in  connection 
with  them.  The  volume  is  well  illustrated  by  16  plates,  each  containing 
several  drawings.  Altogether,  the  book  is  a  complete  and  valuable  compen- 
dium on  the  subject  up  to  the  time  of  its  publication,  and  a  monument  of 
industry  and  patience."  —  British  and  Foreign  Madico-Ghirurgical  Review. 

"  This  is  a  most  complete  and  valuable  work,  treating  in  an  exhaustive 
style  of  a  class  of  affections  on  which  no  complete  systematic  or  practical 
treatise  has  hitherto  been  published.  A  copious  bibliographical  index  is 
given,  and  on  the  whole  the  treatise  is  most  complete,  ranging  throughout 


almost  the  whole  literature  of  the  subject,  and  nearly  exhausting  all  that  is 
to  be  said  on  it  in  the  present  state  of  our  knowledge."  "  The  subject  is  one 
well  worthy  of  the  labor  Dr.  Bodenhamer  has  bestowed  upon  it,  and  worthily 
has  he  worked  it  out." — Dublin  Journal  of  Medical  Science. 

•'The  style  of  this  author  is  concise  and  agreeable,  and  his  subject  inter- 
esting ;  his  work  will  well  repay  perusal,  although  its  immediate  study  may 
not  be  required.  Unfortunately  it  belongs  to  that  class  of  books  which  a 
physician  having  no  cases  of  the  kind  to  treat,  feels  indifferent  in  possessing, 
and  scarcely  willing  to  admit  as  necessary.  It  shows  itself  forth,  however,  in 
bold  relief,  as  one  of  the  most  important  and  useful,  when  he  is  called  to 
operate  on  some  unfortunate  child  thrown  suddenly  in  his  charge.  Glad  of 
the  opportunity  of  examining  its  valuable  pages,  he  will  then  agree  with  us 
on  its  extreme  utility,  and  in  considering  that  no  medical  library  can  be 
called  complete  without  it.  It  is  a  large  octavo  of  upwards  of  300  pages, 
tilled  with  beautiful  lithographs  ;  and  besides  separate  and  distinct  treatises 
on  the  different  species  of  malformation  and  their  treatment,  containing  in 
elucidation  of  the  subject,  upwards  of  200  cases,  gathered  from  every  reliable 
source,  classified  and  tabulated.  By  these  we  find  that  of  156  on  which 
operations  have  been  performed,  87  have  recovered  ;  this  is  encouraging,  for 
of  42  for  which  nothing  had  been  done,  all  but  12  succumbed.  Finally,  50 
pages  are  devoted  to  the  different  modes  of  performing  the  operation  for  ab- 
dominal artificial  anus,  which  are  plainly  illustrated  by  lithographs."— 
Canada  Lancet.  (Montreal.) 

"To  the  practitioner  who  desires  to  be  prepared  for  every  emergency,  we 
commend  this  volume  as  an  indispensable  addition  to  his  library.'' — .  I  mericfin 
Medical  Times. 

"This  is  a  most  valuable  monograph  on  subjects  on  which  little  knowl- 
•jdge  is  to  be  derived  from  our  surgical  books.  The  author  appears  to  have 
fully  elaborated  and  exhausted  the  subject,  having  collected  from  all  sources 
nearly  three  hundred  cases,  and  illustrated  the  most  remarkable  by  16  plates, 
which  are  well  executed,  and  render  the  volume  an  attractive  and  useful  one." 
— American  Medical  Gazette. 

"  This  is  an  opportune  and  valuable  addition  to  the  means  of  acquiring  a 
knowledge  of  the  diseases  of  the  rectum,  which  the  excellent  works  of  Ash- 
ton,  Quain,  Syme,  Bushe  and  Copeland  have  so  clearly  and  fully  furnished  to 
English  and  American  readers.  As  a  practical  monograph  it  is  not  inferior 
to  either  of  these,  so  far  as  it  relates  to  its  particular  department  of  the  sub- 
ject ;  while  it  surpasses  them  all  in  completeness  and  extent  of  illustration, 
and  in  the  facilities  afforded  to  the  student  for  the  purpose  of  further  investi- 
gation. The  work  is  no  empty  compilation,  since  the  author's  views  are 
clearly  and  precisely  given  upon  all  practical  points,  and  many  useful  prac- 
tical details  are  pointed  out  in  a  manner  which  shows  them  to  be  the  product 
of  much  especial  thought  and  observation  as  well  as  practical  skill  and  intel- 
ligence."— American  Journal  of  the  Medical  Sciences, 

"  The  work  before  us  is  one  that  cannot  fail  to  interest  all  diligent  inquirers 
in  the  ranks  of  the  medical  profession,  at  the  same  time  that  it  will  add  much 
to  the  reputation  of  one  of  its  laborious  members.  As  a  monograph  it  may 
be  taken  almost  as  a  model,  while  the  subject  is  one  upon  which  the  profes- 
sion were  little  enlightened,  its  literature  being  principally  scattered  through 
the  published  transactions  of  various  medical  societies,  or  appearing  in  iso- 
lated cases  reported  in  various  medical  journals." 

"  In  conclusion  we  would  merely  say  that  the  volume  which  Dr.  Boden- 
hamer has  given  to  the  profession,  is  most  creditable  to  himself  and  to  the 
profession  in  this  country  ;  and  must  be  considered  by  far  the  most  valuable 
if  not  the  only  text-book  on  this  subject." — Boston  Medical  and  tiurgical 
Journal. 

"  We  give  this  work  of  Dr.  Bodenhamer's  a  cordial  welcome  to  our  table, 
both  on  account  of  the  intrinsic  value  of  the  work  itself,  and  our  esteem  and 
friendship  for  the  author,  who  has  labored  hard  but  successfully,  for  many 
years  in  this  branch  of  medical  science." 


"  The  work  is  unique,  being  the  only  complete,  systematic  and  practical 
treatise  upon  the  subject  ever  published.  It  contains,  in  addition  to  his  own 
vast  experience,  the  productions  and  contributions — to  the  literature  of  this 
subject — of  all  the  eminent  surgeons  of  Europe  and  America — thus  collecting 
and  combining,  in  a  compact  and  condensed  form,  what  has  heretofore  been 
scattered  over  the  two  hemispheres,  in  brief  and  detached  article?,  memoirs 
and  essays,  as  presented  in  the  transactions  of  medical  societies  ;  in  brief 
monographs  ;  in  different  periodicals,  &c." 

"  Dr.  B.  has  devoted  an  immense  amount  of  labor  and  time  in  the  produc- 
tion of  this  valuable  work,  for  which  he  richly  merits  the  thanks  and  the 
gratitude  of  the  entire  medical  profession." — Eclectic  Medical  Journal. 

"Congenital  vices  of  conformation  constitute  many  of  the  most  unfortunate 
disorders  to  which  the  human  frame  is  liable.  Some  of  them  are  incurable, 
either  causing  early  death,  or  allowing  life  to  be  prolonged  in  suffering  and 
deformity  (Spina  Bifida,  Extrophy  of  the  Bladder,  Deformities  of  the  Limbs, 
Phocomele,  <&c.).  Others  are  curable,  but  demand  for  their  relief  the  highest 
resources  of  the  medical  art  (Hernia,  Cleft  Palate,  Hare  Lip,  Club  Foot).  The 
congenital  malformations  of  the  rectum  and  anus  include  representatives  of 
both  these  classes.  Although  of  not  infrequent  occurrence,  they  are  not 
sufficiently  numerous  to  permit  the  general  possession  of  experience  in  their 
management  among  practitioners  ;  so  that  a  practical  treatise  on  the  subject, 
embodying  the  requisite  details  of  diagnosis  and  treatment,  is  of  great  value 
to  the  profession.  The  able  work  of  Dr.  Bodenhamer  before  us  has  this 
merit.  It  is  concise,  full  and  practical ;  and  in  addition  to  this  claim,  possesses 
that  of  being  the  only  complete  and  practical  work  on  congenital  malforma 
tions  of  the  rectum  and  anus  which  'has  ever  been  published  in  this,  or  in 
any  other  country.'  " — Berkshire  Medical  Journal. 

"  This  able  work  of  Dr.  Bodenhamer  will  be  welcomed  by  the  profes- 
sion, as  filling  a  void  which  has  heretofore  existed,  and  as  presenting  the 
opinions  and  reports  of  cases  that  have  been  made  through  journals,  reports 
of  medical  societies,  or  published  as  monographs,  and  were  beyond  the  reach 
of  the  mass  of  the  profession." — Journal  of  Rational  Medicine. 

"  We  cordially  recommend  this  work  to  the  profession." — Savannah  Jour- 
nal of  Medicine. 

"  Is  the  most  complete  work  of  the  kind  that  has  ever  been  published." — 
Medical  Journal  of  North  Carolina. 


WILLIAM    WOOD    &    CO., 

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61  Walker  Street,   New  York, 

Desire  to  call  the  attention  of  the  Medical  Profession  to  their  stock  of  Medi- 
cal and  Scientific  Books.  Having  made  this  a  specialty  for  forty  years,  they 
have  acquired  a  thorough  knowledge  of  the  business,  and  an  acquaintance 
with  Medical  literature,  which  enables  them  to  serve  the  Profession  as  effect- 
ually aa  promptly.  They  have  on  their  shelves  by  far  the 

LARGEST  STOCK  OF  MEDICAL,  BOOKS 

in  the  country.     Their  assortment  of 

A.NTA.TOMIC.AX,   PLA.TES 

is  large  and  peculiarly  adapted  to  the  wants  of  the  Medical  Profession,  both 
for  Office  and  Lecturing  purposes. 

5j^°  Priced  Catalogues  sent  gratis  on  application. 

I^T  Gentlemen  visiting  the  city  are  invited  to  drop  in  at  any  time  they 
may  have  leisure. 


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Return  this  material  to  the  library 

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WI  620 
B666p 

Bodenhamer,  William. 

The  physical  exploration  of 
the  rectum 


WI  620 
B666p 
1870 
Bodenhamer,  William. 

The  physical  exploration  of  the 
rectum. . . 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


